Title Page
-
Site conducted
-
Conducted on
-
Prepared by
-
Location
Untitled Page
-
Time released:
-
Incident Date:
-
Incident Time:
-
Received Call:
-
Time presented:
-
Date:
-
Patient's First Name:
-
Patient's Surname:
-
Patient's Mobile:
-
Patient's Employer:
-
Patient's BU:
-
Patient's Department:
-
Patient's Occupation:
-
Pregnant: Y / N
-
Date of birth:
-
Gender:
-
Emergency Contact:
-
Relationship:
-
Aware? Y / N
-
Mobile:
-
Immediate Supervisor:
-
Position:
-
Aware? Y IN
-
Mobile:
-
Person Performing Investigation:
-
Position:
-
Aware? Y IN
-
Mobile:
-
LPS Contact if Contractor.
-
Position:
-
Aware? Y / N
-
Mobile:
INJURY / ILLNESS
ALLERGIES
-
First time reporting injury / illness? Cority
-
Review or follow up appointment? No Cority
-
Chief complaint:
-
History of injury / illness - Description of Event not the Resulting Injury:
PAST MEDICAL HISTORY
-
Floor area where incident occurred Use reference tool:
MEDICATIONS
-
Immediate actions taken by worker if any:
-
Observations and assessments:
-
LAST INS
-
LAST OUTS
-
LOSS OF CONSCIOUSNESS
-
Witnessed: Y / N
-
Duration:
MOTOR VEHICLE COLLISION
-
Seatbelt worn? Y / N
-
Helmet worn: Y / N
-
Estimated speed:
VITALS
-
GCS
-
Time
-
Pupils
-
ECG
-
PR
-
B.P
-
VR
-
SpO2%
-
B.S.L
-
Temp
-
Pain
-
Eye
-
Verb
-
Motor
-
Total
OBSERVATION REFERENCES
-
Glasgow Coma Scale
-
Pupils
-
ECG
-
Eyes
-
Verbal
-
Motor
-
1
-
P.E.A.R.L.A
-
1
-
Normal Sinus Rhythm
-
1/2
-
6
-
n/a
-
n/a
-
Obeys commands
-
2
-
Pinpoint
-
2
-
Tachycardia
-
5
-
n/a
-
Oriented
-
Purposeful movement
-
3
-
Dilated
-
3
-
Bradycardia
-
4
-
Open spont
-
Confused
-
Withdraws to pain
-
4
-
Reactive
-
4
-
Ventricular tachycardia
-
3
-
Open to voice
-
Inappropriate
-
Flexion to pain
-
5
-
Non-reactive
-
5
-
Ventricular fibrillation
-
2
-
Open to pain
-
Incomprehensible
-
Extension to pain
-
6
-
R>L
-
6
-
Asystole
-
1
-
none
-
none
-
none
-
7
-
L>R
-
7
-
Pulseless Electrical Activity
TREATMENT
-
Adult skin area
-
Head and neck 9%
-
Torso
-
36%
-
Arms
-
18%
-
Legs
-
36%
-
Perineum
-
1%
-
100%
Outcome Post Assessment & Treatment
Abbreviations
-
Resumed normal duties
-
Placed on precautionary restrictions
-
A
-
Abrasion
-
L
-
Laceration
-
Hospital via SAAS - Inform Rick ASAP 24/7
-
Sent offsite for further treatment - Inform IMT
-
B
-
Burn
-
P
-
Pain
-
Inform IMT when any worker sent offsite: Rick or Kelsey via phone (serious 24/7) or text (non-serious & after hours)
-
C
-
Contusion
-
S
-
Swelling
-
Provide additional outcome details:
-
D
-
Deformity
-
T
-
Tenderness
-
F
-
Fracture
-
W
-
Wound
-
H
-
Hemorrhage
-
REDIMED permission to administer schedule 4 drugs? Y / N
-
REDIMED contact made: Y / N
-
Consulting doctor:
-
Details of any advice provided:
-
PATIENT REFUSES TREATMENT
-
Patient declaration:
-
Witness name:
-
Signature:
-
Patient name:
-
Signature:
-
ADDITIONAL COMMENTS
-
ADDITIONAL ADMINISTRATION
-
Medical release form signed: Y / N
-
Injury management team details provided to PT with further instructions? Y / N
-
TREATING MESO / PARAMEDIC
-
Signature:
-
Name:
-
Signature:
-
Name:
