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What should be displayed on an emergency medical record?
Details of the patient. Details of the diagnosing and treating medical doctor. Details of the patient. Where is the patient now? _________________________ How old is the patient? _________________________ What is the gender of the patient? _________________________ Who is reporting this emergency? _________________________ What are the sources of medical history? _________________________ Patient. Family. Patient not responding to medical history questions. Community member. Police officer. Referral from medical doctor. Other. What is the reason for consultation? _________________________ What seems to be the problem? _________________________ How much time has elapsed from the start of the emergency until now? _________________________ Does one individual or many individuals have medical emergencies at this location? _________________________ How many individuals have medical emergencies at this location? _________________________ Is it a Medical Emergency? ___________________________ Is the victim's condition life or limb threatening? ___________________________ Could the victim's condition worsen and become life or limb-threatening on the way to the hospital? ___________________________ Could moving the victim cause further injury? ___________________________ Does the victim need the skills or equipment of paramedics or emergency medical technicians? ___________________________ Would distance or traffic conditions cause a delay in getting the victim to the hospital? ___________________________ What best describes your problem? _________________________ Patient Name:________________________ Referred by:_________________________ Mailing Address:_____________________ Telephone:___________________________ Your Email Address:__________________ Date of Birth:_______________________ Gender: Male Female Primary Care Physician Name, Address and Phone:__________________ Emergency Contact Name:______________ Relationship:________________________ Phone:_______________________________ Your Height:_________________________ Your Weight:_________________________ Race::_______________________________ White Black/African American Hispanic/Latino Pacific Islander Asian Asian/American Consciousness of a human being has to be included in vital signs. Vital Signs Consciousness, pulse, blood pressure, respiratory rate, temperature. Consciousness is extremely essential in reaching a correct diagnosis and treatment. What are the vital signs on the date and time of diagnosis and treatment?
http://www.qureshiuniversity.com/medicalhistory.html http://www.qureshiuniversity.com/vitals.html Are there any obvious injuries? What are they? Where was patient when the injuries occurred? 1. inside other building ______________________________________ 2. outdoor location ___________________________________________ 3. unknown Date of first E.R. Visit ____/____/____ Arrival Time :______________ How did patient get to hospital? 1. ambulance (name company____________________________) 2. private vehicle 3. public transportation 4. walked or was carried 5. helicopter 6. other (specify________________________________) 7. unknown Was the patient transported from another health care facility? Y/N Unknown If yes, specify: ________________________________________ Disposition from Emergency Department 1. discharged home 2. admitted 3. transferred to other facility (specify _________________________________________) 4. left against medical advice 5. dead on arrival 6. expired in emergency department 8. other (specify___________________________________________) 9. unknown If patient was admitted: Date of Admission ____/____/____ Date of Discharge/Death ____/____/____ Discharge Disposition: 1. home 2. acute care hospital _____________________________ 3. skilled nursing facility __________________________ 4. intermediate care facility ________________________ 5. other hospital ___________________________________ 6. home health care 7. left against medical advice 8. expired in hospital 9. other _________________________________________ 10. unknown | ||||||||||||||
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How did injury occur: Injury Report Form | ||||||||||||||
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Are long-term physical disability/sequelae likely? ___definite ___likely ___unlikely ___unknown If so, what type of disability? ___neurologic ___physical ___hearing ___vision ___ other |
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Details of the diagnosing and treating medical doctor.
What is the name, date of birth, phone number, and other contact information of the person diagnosing and treating this patient? _____________________________________________ What is the date and time you are diagnosing and treating this patient? _____________________________________________ What is the location of the patient at the time you are diagnosing and treating this patient? _____________________________________________ What best describes the location of diagnosis and treatment of this case?
_____________________________________________ What is the diagnosis of this patient? _____________________________________________ How did your reach this diagnosis? _____________________________________________ What is the treatment for this patient? _____________________________________________ Does the patient need to be transferred to a medical emergency room? _____________________________________________ In America up to February 12, 2012, most emergency medical records did not have these facts. In what emergency medical category do you fit the condition of the patient you are diagnosing and treating on this date and time? Undetermined, Good, Fair, Serious, Critical. If on-the-spot diagnosis of a patient declared in serious or critical condition, arrange a bed in the Intensive Care unit. How are most patients categorized in American triage locations up to February 12, 2012? Immediately life threatening Urgent, but not immediately life threatening Less urgent How should patients be categorized around the world, including in America, in case of a medical emergency? Undetermined, Good, Fair, Serious, Critical. Fair, serious, or critical will always get a medical diagnosis that needs emergency treatment. This can be only done by an emergency medical doctor able to reach the correct diagnosis and provide treatment. Is there a difference between emergency and non-emergency medical diagnosis? Yes, there is. What is the difference between non-emergency and emergency medical diagnosis? This example will make you understand. Diabetes is a non-emergency medical diagnosis. Diabetes with hyperosmolar coma or diabetic ketoacidosis is an emergency medical diagnosis. Date of Examination:_________________________ Physician Name:_________________________ Physician Address:_________________________ | ||||||
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Annual health assessment. Here are further guidelines. | ||||||
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Surgical history.
Have you ever undergone surgery? (Yes / No) If yes, please list operations and dates: Social history Do you smoke now? (Yes / No) How much? __________________ Have you ever smoked? (Yes / No) If yes, for how many years? ________ When did you quit? _______________ Do you drink alcohol? (Yes / No) If yes, how much? __________________ How often? ___________________ Have you used recreational drugs? (Yes / No) If yes, which ones? _______________________________________________ When was the last time you used one/them? ___________________________ Allergies Are you allergic to anything (medications, foods, latex)? (Yes / No) If yes, please list: Do you need assistance with getting around( ie cane, wheel chair, etc)? (Yes / No) Do you exercise? (Yes / No) (For women only) Are you pregnant or breast feeding? _____________________ Date of your last menstrual period: ______________________ How many children do you have? ______________________ How were they delivered? ______________________ Human Vital Signs 1. Consciousness:_________________________ 2. Pulse rate:_________________________ 3. Blood pressure:_________________________ 4. Respiration rate:_________________________ 5. Body temperature:_________________________ 6. Emotion:_________________________ Vital Signs. These are some vital signs checked by your doctor: Blood pressure: less than 120 over 80 is a normal blood pressure. Doctors define high blood pressure (hypertension) as 140 over 90 or higher. Heart rate: Values between 60 and 100 are considered normal. Many healthy people have heart rates slower than 60, however. Respiration rate: Around 16 is normal. Breathing more than 20 times per minute can suggest heart or lung problems. Temperature: 98.6 degrees Fahrenheit is the average, but healthy people can have resting temperatures slightly higher or lower. Vision & Hearing Screening Height:_________________________ Weight:_________________________ Waist, hip circumferences:_________________________ BMI:_________________________
< 20 BMI Low body weight 20 to 25 BMI Healthy weight for most people >25 to 27 BMI Weight may lead to health problems 27 to 29 BMI Overweight. Associated with increase in morbidity and mortality. > 30 BMI Obese Ears/Nose:_________________________ Oral Cavity:_________________________ Endocrine:_________________________ Lymph Nodes:_________________________ Lungs:_________________________ Heart:_________________________ Breasts:_________________________ Abdomen:_________________________ Genitals:_________________________ Female Physical Exam:_________________________ Male Physical Exam:_________________________ Extremities / Musculoskeletal:_________________________ Habitus:_________________________ Skin:_________________________ Psychiatric:_________________________ Neurologic:_________________________ Laboratory Tests Complete blood count Chemistry panel Urinalysis (UA) Prescription Here are further guidelines. |