Full Patient Care Record
To be completed for all patients requiring intervention or assessment by Nexus Staff.
Nexus Event ID#
*
Found on breifing sheet
Personal Details
Name
*
First Name
Last Name
Gender (at birth)
*
Please Select
Male
Female
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Email (If Patient Would Like Copy of PCR)
example@example.com
Patient Medical History
Medication Allergies
Medical History
Treatment
Presenting Complaint
*
Chest Pain, Fall, Arm Injury etc
Location at Event
*
Arena, Stage, Field etc
Capacity Assessment
*
Please Select
Patient Deemed To Have Capacity
Patient Does Not Have Capacity
Assessment & Treatment Notes
Please Follow - O/A, HxPC, O/E, Plan etc Format
Observations
*
Medication Administered / Prescirbed
For all Nexus POMS, ensure a POM usage form is completed.
Disposition
Patient Disposition
*
Please Select
Treated & Discharged
Treated & Conveyed
Self Conveyed to ED
Self Conveyed to MIU
Refused Treatment
Without Nexus Intervention would this patient of needed NHS input?
*
Please Select
YES
NO
For example - wound closure, antibiotics, ambulance conveyance etc.
Nexus Staff Name
*
First Name
Last Name
PRF Completed By (Staff)
*
Patient Signature (Refusal / Non Conveyance)
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Should be Empty: