Patient Care Record

	Comment
Onset of Pain
Location of the pain- RUQ, LLQ, hypogastric etc
Description of the pain- sharp, ache etc
Does the pain radiate
Aggravating factors- movement, urinating etc
Any relieving factors
Any rebound tenderness
Any associated symptoms- sweating, nausea, vomiting
Normal bowel movements
Any difficulty urinating
Hx of the same pain

	Comment
Onset (Gradual, Rapid or Thunderclap)
Duration
Location
'Normal' or 'Different' Headache
P/Hx Headache/Migraine
Triggers
Nausea
Vomiting
Altered Sensation
Neck Stiffness
Rashes
Fever (Temp >38)
Medications in the last 4 hours
Age risk (>50) or pregnancy (Mx caution)

	Action taken
Action 2: Concussion assessment performed - No suspected concussion.
Action 3: Concussion Suspected Any athlete with a suspected concussion must be removed from play immediately – NOT TO RETURN. Vital signs survey every 5-10mins Observed for a minimum of 20mins – unless urgent 000 or hospitalisation required.
Action 4: Complete resolution of symptoms with no initial LOC If observations are within normal ranges – patient may be sent home with a parent, guardian or responsible. Instruct to observe for the next 4 hours – if any changes or symptoms return to call 000Explain and given “Concussion advice sheet” - Recommend SCAT assessment.
Action 5: Symptoms NOT resolved – Patient to go to Emergency Dept. If symptoms are NOT COMPLETELY resolved and no new symptoms and no initial LOC – Use judgement, patient is to go to the hospital ED with a parent or responsible adult immediately and not via home. Judgement depending on severity, ambulance delay or distance to nearest appropriate ED.Instruct if any symptoms worsening on route or unsure to call 000

	Comment
How many weeks pregnant is the patient?
Is the patient expecting singleton or multiple pregnancies?
How many previous pregnancies, if any, has the patient had?
What was the patient's length of the previous labours?
Has there been any complications with any of the previous pregnancies? If yes, please elaborate.

	Comment
When did the contractions start?
How long does each contraction last for?
How long is there between each contraction?
Are the contractions getting closer to each other?

Discharge Summary
Discharge Advice*
Please specify other Discharge Advice
E.g. Follow-up with GP
Discharged to*
Discharge Time

HH MM
Time in Care
Auto generated - Do not edit!
Hour DischargeTime (hidden field needed to calculate)
Time Ambulance Called*

HH MM
Time Ambulance Arrived*

HH MM
Ambulance Departed*

Hour Minutes
TotalMinutes DischargeTime (hidden field needed to calculate)
MinutesDifference DischargeTime (hidden field needed to calculate)
AV Response Time
Patient Signature
Witness Involved

YesNo
Note: Contact details are required when entering a witness name. Please ensure they are aware that they may be contacted for information about this incident.
Witness Name

First NameLast Name
Relationship to Patient
For Example -> Trainer, Medic, Parent, Teacher
Witness Phone
Please enter a valid phone number.
Witness Signature

Clear

Refusing Care - Colmed Medics Release from Liability by Patient*

Yes
Date

DayMonthYear
Date
Patient Still Here - Patient Declaration?*

YesNo - Unable to obtain
You are signing this form because you have refused treatment, or discontinued treatment, by Colmed Group and/or transport by another available EMS agency. Your health and safety are our primary concern; please remember the following:*

The evaluation and/or treatment provided to you is not a substitute for medical evaluation and treatment by a doctor. We advise you to get further medical evaluation and treatment as soon as possible.Your condition may not seem as bad to you as it actually is. Without treatment, your condition or problem could become worse. If you are planning to get medical treatment, a decision to refuse treatment or further treatment by Colmed Group, or transport by another available EMS agency, may result in a delay of care which could make your condition or problem worse.Medical evaluation and/or treatment may be obtained by calling your doctor, if you have one, or by going to any hospital Emergency Department in this area, all of which are staffed 24 hours a day by an Emergency Physician. You will be seen at these Emergency Departments without an appointment.If your condition becomes worse or changes, we encourage you to call ‘000’ without hesitation.
I acknowledge I have received the above advice and release Colmed Group from any liability as a result of my refusing additional care.*

Yes
Patient Name *

First NameLast Name
Witness Name

First NameLast Name
Patient's Signature*
Witness Signature
If you are the patients legal guardian in this situation and are acting on behalf of the patient, by signing below you indicate you have read and understood the above information regarding refusal of treatment, or further treatment, and/or transport. I acknowledge I have received the above advice and release Colmed Medics from any liability as a result of my refusing additional care.*

Yes
Relationship to Patient
Phone Number
Guardian's Name

First NameLast Name
Guardian's Signature

Clear

	Medications	Route	Dose	Freq
1
2
3
4
5

	Yes	No
Pain
Loss of function
Deformity
Tenderness
Distal perfusion
Rotation
Unnatural movement
Minor Swelling
Major Swelling
Bruising
Irregularity
Crepitus
Able to flex
Able to extend

	Yes	No
Recent increased use of medications?
Anxious/Distressed
Tripoding
Tracheal Tugging
> Expiratory Phase
Increased Accessory Muscle Use
Expiratory wheeze/silent chest
"Pursed lipped" breathing
Prior ICU or A&E admissions for asthma

	Yes	No
Tackle to ground / whiplash
Collision with player (with/without head strike)
Moderate / high impact to the head
Other force / trauma applied (specify)

	Yes	No
Have you experienced any miscarriages / stillbirthes in the past?
Does the patient have any history of previous caesarian section or interventions?
Does the patient have any any antenatal care?
Has the patient’s membranes (water) ruptured?
Has the patient passed her mucus plug?
What was the patient's length of the previous labours?
Has there been any complications with any of the previous pregnancies? If yes, please elaborate.
Are there any anticipated complications with the mother or the baby?
Has the patient felt recent fetal movements?

Patient Care Record

Shift Information

Patient Information

Privacy Statement

Injury Details

Soft Tissue / Fracture Assessment

Abdominal Pain

Headache Assessment

Stroke Assessment

Facial Movements

Arms

Speech

Major Burns

Mental Status Examination

Anaphylaxis

Asthma Assessment

Concussion Management Tool (Sports Only)

Obstetrics Assessment

Trauma Assessment

Neck Assessment

Vitals & Assessment

Paracetamol Assessment

Discharge Summary

Medic Summary

Review

OLD OTTAWA Assessment

Fracture Assessment Tool OLD

	Yes	No
Pain
High blood pressure (SBP>170 or DBP>110)
Vaginal bleed / PV loss
Trauma

	Yes	No
Does the patient have the urge to push?
Is the patient actively pushing?
Is birth imminent?

	NAD	YES
Mechanism/Force
Head
Neuro
Face
Chest
Upper Limbs
Abdomen
Back
Pelvis
Lower Limbs
Limb threatening injury

	Yes	No
1. Has the patient had any medications containing paracetamol in the last four hours?
2. Is the patient under 50kg? If yes the patient can only be administered 1x500mg paracetamol tablet.
3. Does the patient have an allergy to, or ever had adverse reactions to paracetamol?
4. Is the patient under 18 years of age? (If yes, parental/guardian permission required)
5. HR & BP measured are they within normal range?
6. Patient suitable for paracetamol?

	Yes	No
Bone Tenderness at 'A' (Posterior edge or tip of lateral malleolus)
Bone Tenderness at 'B' (Posterior edge or tip of medial malleolus)
Inability to bear weight immediately after injury. (Pt unable to take 4 steps)

	Yes	No
Bone Tenderness at 'C'
Bone Tenderness at 'D'
Inability to bear weight immediately after injury. (Pt unable to take 4 steps)

	Yes	No
Direct Impact
Moderate Impact
High Impact
Hyperextension/ Hyperflexion
Twisting/ Rolling
High Tackle
Head Strike
Player to player contact

	Yes	No
Pain
Weight bearing
Full ROM
Obvious deformity
Dislocation
Hips firm

	Yes	No
GCS 15
LOC witnessed
LOC unwitnessed
PEARL, normal size, tracking
Visual disturbance
Vomiting or nausea
Dizziness
Headache
Amnesia
Normal speech
Slurring
Steady Gait
Falling GCS

	Yes	No
Puff cheeks
Protrude tongue
Raise Eyebrows
Smile
Move jaw
Teeth intact
Obvious facial features
Epixstasis
Contusion
Laceration
Globe trauma

	Time	Pt position	RR	HR	BP	BGL	SpO2	Temp	Pupils	Pain Score
1
2
3
4
5
6
7

	Time	RR	HR	BP	BGL	SpO2	Temp	Pupils	Pain Score
1
2
3
4
5
6
7

	Time	Skin	Appearance	Speech	Breathing Sound	Resp Rythym	Auscultation	Breathing Effort
1
2
3
4
5
6
7
8
9
10

	Time	Eye Opening	Verbal Response	Best Motor Response	Total GCS
1
2
3
4
5

	Yes	No
Normal RR
Normal breath sounds
Normal WOB
Contusion/laceration
Chest pain on deep inspiration

	Yes	No
Instructed to stay still/no neck movement
C-Spine Stabilisation applied
Neck or back pain
Pain on midline or lateral palpation
Obvious deformity
Abnormal sensation
Loss of strength in any limb
Cervical dermatomes normal:
Altered sensation
- Arms
- Hands
- Fingers
- Upper shoulders
- Upper back
Normal bilateral grip strength
Shrugs shoulders
Normal chest wall movement
Normal body motor function
Normal strength in all limbs
Incontinence
Priapism
Hypotension

	Yes	No
Loss of consciousness or prolonged immobility (> 2 seconds)
LOC GCS <15 at any time
Headache
Nausea / Vomiting
Visual Disturbance
Slow to recover
Balance disturbance (loss of control over movements)
'Not quite right'
Dazed, blank/vacant stare or not their normal selves
Unusual behaviour change
Confusion or disorentation
No protective action in fall to ground (not bracing for impact)
Impact seizure (stiffening arms or legs on impact)
Other symptoms (specify)

	Yes	No
Is there pain?
Is the limb pale and cool to touch?
Is there partial or full paralysis of the limb?
Is the patient experiencing paresthesia in the limb?
Is there a strong pulse present in the limb?
Is the patient experiencing poikilothermia in the limb?
Does the patient have any difficulty breathing? (suspected rib fracture ONLY)
Is the limb Neurovascularly compromised?