EmailMe Form - Cockburn ARC - First Aid Report

Patient details

Patient Name *

First Last

Patient Date of Birth *

DD / MM / YYYY

Guardians name (if under 18)

First Last

Best contact number *

Injury details

Where did the injury occur?

Date & time of injury *

DD / MM / YYYY HH : MM AM/PM

Injury Location - Other

Provide further detail regarding where patient acquired the injury

Injury description *

Describe the patient's injury and the injury location on the patient's body

Patient assessment

Ask each question of patient and document the responses

Symptoms *

What symptoms were demonstrated by the patient - for example bleeding, shortness of breath, loss of consciousness, sharp pain

Allergies?

Does the patient have any known allergies?

Known allergies

List known allergies of patient

Medications?

Does the patient take any medication/s?

Medications

List any medications and dosages patient described

Past history?

Have there been any related injuries or incidents that may have compounded or contributed to this injury? Example - experiencing chest pain, previously had a heart attack

Last intake of food or liquids?

DD / MM / YYYY HH : MM AM/PM

Events leading up to the injury?

What was the patient doing immediately prior to the injury? How did the injury occur?

Treatment

Patient Treatment

List any treatment provided

Oxygen administered?

Oxygen treatment duration:

Start time
Oxy Saturation pre-treatment?
Finish time
Oxy saturation post-treatment?

Please use the oximetre to track the patient's oxygen saturation levels.
Patients with COPD have lower oxygen saturation levels, running between 88-92%
Anyone without COPD should have a normal range of 98-100%

Recommend to seek medical advice? *

We always recommend to seek medical advice should symptoms persist

Ambulance Contacted? *

Response time

Time Called
Time Arrived

Instructions given by 000 operator?

List any treatment that was performed as a result of the 000 operators instructions

Follow up needed? *

Does the Supervisor need to call this person tomorrow to follow up with them?

Sign off by Patient/Guardian and Staff

Signature of patient or guardian *

Clear

Staff Signature *

Clear

Staff Name *

First Last

Supervisor Notified?

Have you notified the supervisor of your area?

ECM