ASSESSMENT QUESTIONS / STRUCTURED PRF WRITE UP – MEDICAL MODEL

PC: Presenting complaint? (Medical or Trauma) OA: Trauma: SCENE - Safety? Causes MOI? Environment? Number of patients? Extra resources needed? M/ETHANE? Triage

Medical: Age? F♀M♂? PT location? Presenting? Found: weight baring/prone/supine/sat upright? Clenching? Company of? Analgesia/TX applied?

PS: Every patient to be treated as time critical (TC) until proven otherwise & take no longer than 90 sec’s to complete! New born: APGAR - Airway/Appearance? Pulse? Grimance? Activity (muscle tone)? Respiratory rate/effort? Child: AVPU? Airway patent? Appearance? Tone? Interactiveness? Consolability? Look/gaze? Speech/cry? Breathing effort Normal? Nasal flaring? Grunting? Hoarseness? Trachea tug? Intercostals recession? Diaphoretic? Circulation: Pallor? Mottling? Cyanosis? Adult: AVPU? Airway patent? Breathing adequate? Full, Regular, IRR, Weak radial/carotid pulse/ blood loss? Disability / FAST / vitals ob’s? New pain? Trauma: Catastrophic bleed? Airway patent? C-spine? Breathing adequate? FLAPS TWELVE? Radial/Carotid/Distal pulse? Disability: GCS? Vital ob’s? Exposure: DCAP BLS? CONSENT GIVEN: Yes/ No? If no why? - Assess mental capacity HPC: Events leading to PC - If faced with one of the following document these keywords in your write up Mental health: Acute/Chronic? Depressed? Suicidal? Behaving: Violet, Aggressive, Non/Cooperating? Intent: To die? Why? Consequence of actions? Emotionally Un/Stable? Anxious? Delusion? Hallucination? Un/Able to focus? Rational thinking? Controlled by external forces? Plan: How? Alcohol/Drugs consumed? Action: Injury? Previous attempts? Protective measures: Current care package? Family/friends Support? Working? Goals/Ambitions? Immediate risk to self / Others? Dependants? Appearance? Living environment? JRCALC & IPAP risk score? Trauma: - Age? Time? Mechanism: Collapse/Fall: Un/Witnessed? From: Standing/Sitting/Height? On to/surface? Time? How? (Mechanical, Posture, Provoking, Prodromal, ? Course) Un/Able to self rise? RTC: Vehicle? Vs? MPH? Protective clothing/Helmet? Seat belt? Airbags? Rollover? Bull’s-eye? Decamped/Trapped? Damage? Rd surface? Visibility? Injury? Signs and Symptoms? TX applied? Help activated by? PREG: Gestation? EDD? Under Midwife/Consultant care? Witch hospital? Para? PV bleed? Show described (Date/Time)? Pain (SOCRATES)? Contracting? Lasting? Reg/ IRR? Onset? SROM? Meconium? Fetal movement? Push down? Crowing? Complication/Miscarriage? Birth plan? VB/Cesarean birth? Primary PAIN: Acute/Chronic? Site (anterior/posterior)? Onset/time? Character? Radiates? Associated symptoms? Time/duration? Exacerbating/relieving factors? Score? PMH: Any history of PC? Past medical history? Last seen doctor/hospital admission PSx: Recent / Past surgical history? Body organs removed? ALLERGIES: To medication? Foods? Creams? Bandages? Plants? Anything? What happens? Anaphylaxis? DHx: List all prescribed medication (POM)? Compliant? Taken in <4hrs? New POM/Changes? Recreational drugs? Anticoagulants? Chemotherapy? MENTAL CAPACITY: Capacity = Yes / No? Why? Use CURE in the text below to assess mental capacity & document using Trust guidlines OE: Trauma: Physiological, Anatomical, Mechanism, Special considerations? Blunt/Penetrating trauma? Where? Abrupt/Gradual stop? Intoxicated? CNS (Nervous): Brain & Spinal cord PNS, Eyes, Ears, Taste buds? 12 Cranial nervous Hypoxia, Concussion, Stroke TIA CVA, Absences, Atonic, Tonic, Tonic clonic, Status epilepticus, Decorticate flexion/extension Q: Head injuries (<3 months)? A&OX3? GCS? Unusual smells? Visual disturbance? PERL? Size? Colour? Photophobic? Nystagmus? Dysarthria? Peripheral vision? Facial palsy? Paraesthesia? Dermatomes intact? Hearing loss? Unusual tastes? LOC? Headache? Nuchal rididity? Vomiting? Lethargic? Accessory /Arms/legs/weakness? Ataxia? Clench buttocks? Paralysis? Tongue deviation? ABCD2 score? Bleed? Seizure: How many? Duration? Type? Febrile? Tonic/Clonic? Decorticate /Decerebrate posturing? Incontinent? Cerebrally irritated/Combative/Postictal? Aura? Neurological deficit found? Onset? Resp (Respiratory): Nose, Pharynx, Larynx, Trachea, Lungs, Bronchi, Bronchioles, Alveolar ducts, Alveoli Non-oxygen atmosphere - Obstruction of air passages - chest or lung trauma - lung disease & illness - Paralysis of respiratory nerves and muscles Q: I: Breathing effort: Reg/IRR? Un/Laboured? Audible sounds? Swellings? FBAO? Central/Peripheral cyanosis? P: Un/Equal expansion? Pulseness paradouxus? P: Dullness, Hyperresonance? A: Wheeze, Rhonchi, Crackles, Pleuritic rub, ↓ sounds? inspiratory restriction? Other: Tidal volume? Resp rate? Thoracic injuries? Dyspnoea: Rest/OE/PND? Sp02? C02? PFR? Cough? Sputum colour? ICU/intubated? Wells score? Talking in full sentences? Finger clubbing? Respiratory compromise? CVS (Cardiovascular): Heart, Artery - Arteriole - Capillary - Venule - Vein, Blood Coronary Artery Disease - Acute Coronary Syndromes – Angina/pectoris - Heart Failure - Aortic dissection - Cardiac Arrest I: Conjunctival pallor? JVD? CRT Pacemaker? </> 2 sec’s? Splinter haemorrhage? Janeway lesions/Oslers nodes? P: Reg/IRR? Radio-radial delay? Collapsing pulse? Sacral/Peripheral oedema? Swollen calves? Limbs/Feet: Warm/Cold? A: S3/S4/Murmur/Muffled sounds? Other: CP? Lasting 15>min’s? Palpitations? HR? Reg/IRR? Present: PQRST? PR/QRS/QT WNR? Rhythm? STE/ischemic changes? High risk ACS/NSTEMI symptoms? BP L/R Arm/Standing? MAP? Blood conditions? Shock? LYMP (Lymphatic): Thymus, Spleen, Lymph nodes (Sepsis = PR >90, Resp >20, BM >7.7, Temp <36 or 38>, Reduced GCS, Route for infection / Hypotension) Q: Temp? Resent Infection? Where? Sepsis? Meningitis criteria? Immunodeficiency? On steroids? Vaccinations? New/Unusual lumps? Route for infection? GIT (Digestive): Mouth, Pharynx, Oesophagus, Stomach, Duodenum, Pancreas, Small/large intestine, Liver, Rectum SB821217 Internal Bleeding - Peptic Ulcer - Diverticulitis - Abdominal Aortic Aneurysm - Kidney Stone - Ectopic Pregnancy - Pelvic Inflammatory Disease - Appendicitis Q: I: Abdominal injuries inc Spleen/Liver/enlarged? Cullen’s/Grey Turner's signs P: Guarding? Distension? Rebound/Tenderness? Rigidity? Swelling? Hard/Pulsating mass? Hernia? Psoas/Murphy’s +/-? P: Ascites? A: Bowel sounds? Other: Haematemesis? Appetite? Odynophagia? Last meal? Breast feeding/Bottle/Solids? Bloated? Weight ↓or ↑? PT weight? BM? Nausea? Last bowl movement? Diarrhoea/Melaena/Constipation/PR bleed? Electrolyte imbalance? Back pain/ache? Urinary: Kidneys, Ureter, Bladder, Urethra, (30mL per hour – normal) Q: Alcohol? H2O intake? Urine output? Fluid retention? <500ml per day? AKI? Polyuria? Pains? Unusual smells? Colour? Haematuria? UTI? Catheter? Reproductive: Penis, Testicles, Uterus, Vagina, Ovary, Cervix Q: PV bleed? LMP? Normal? Spotting? Pregnant? Ectopic? Hysterectomy? Birth control/contreptive? Endometriosis? Testicular torsion? Priapism? MSS: Skeleton, Joints, Tendons, ligaments and muscles – Sprain, Strain Dislocated – Fractures Open, Closed, Broken - Skull: Linear, Depressed, Basilar Q: Deformities? Contusions? Abrasions? Bruising? Lacerations? Swellings? 6 P’s of limb ischemia? Head: Bogie mass? Battle/Raccoon eyes? CSF? Skull #? Vertebrae: C1 to L5 Tenderness/Pain? JRCALC immobilisation Not/Req? Thoracic: Flail segments? Collar/ Rib #? Pelvis: Symmetrical? #? Long bone: Shorting/rotation? Other: Weight bare? Walk unassisted /with aid? Over what distance? GAIT? Grimace? Stiffness? Tenderness? Crepitus felt? ROM/Joints? MSC? TUAG ? sec’s? Brittle bone disease? Open/Closed #? Skin (Integumentary): Epidermis - Dermis – Subcutaneous tissue - Connective tissue Q: Clammy? Pollar? Tenting/Dehydrated? Jaundice? Rash? Hives/Urticaria? Scares? Abuse? Cellulitis? Pressure/sores? Burn type 1,2,3,4? Critical skin? Open Endocrine: Pituitary gland, Pineal gland, Thyroid, Spleen, Pancreatic islets of langerhans, Kidney Q:Thyroid problems? Diabetes? IDDM (insulin-dependent diabetes mellitus) DKA? Adrenal crisis? SH /FH: FHx Of PC? Daily alcohol intake? Smoker? Recreational drugs? Appearance? Living environment/with who? Dependants? Carers? Working? Recent travel? IMPRESSIONS: PT Reported/looks & feels un/well? What conclusion hare you reached about the PC? RED FLAGS / DDx: What have you identified of concern? Differential diagnosis (DDx)? Risk factors? NEWS? SAFEGUARDING: No / Yes (document concerns)? Emotional, Sexual, Physical, Neglect, Acopia? Who did you report the safeguarding to? Reference numbers? PLAN: 1: Reassure 2: Tx 3: Reassess 4: Discuses red flag 5: Consult & Instigate Acute/Pathways/Protocol? Advise A&E? Accepted/Declined? How mobilised/extracted? Reassess? Pre-alert? Transport & monitor on route to? In the Recumbent, Semi-recumbent, Upright, Lower limbs raised, Fowler, Trendelenburg, Recovery position? Who accompanied? OA – GCS? ABC/pain score? H/O to? NEWS? Couldn't do / why? Other personnel / services present / call signs? Refusing? Document (CURE): PT declining aid / transport against advice despite multiple attempts to reason. Crew able to Communicate rationally with PT (face-to-face, over phone, via 3rd party )? PT Understands & weigh up red flags? PT able to Retain and recite concerns? Provide Explanation (write down why) without External pressures? Ethanoic or Iillicit drugs? Cognitive impairment? Mental capacity: (Yes) PT assessed to have MC & able to make an informed decision regarding limitations of pre-hospital diagnostic & Tx that can lead to a premature death. Metal capacity form number (No) Other services involved? Staff PIN? VAF? Sectioning? Worsening advice: If you notice a deterioration in health, LOC or concerned in anyway call 999 or seek advice from 111. To monitor for (list)? A pathway has been put in place for a HCP to either call/visit ref: XXXX. Advised to visit own GP ASAP & read instructions regarding POM’s. PT left in care of? Who was able to recite advice back to? All on scene happy with decisions made? Note all other HCP details involved? A copy of PRF & 12 lead ECG left with PT. Note all document numbers eg:SB171282 Leaving scene a 3rd set of ob's. IF IT’S NOT ON THE PRF IT DID NOT HAPPEN!

Pre-alert ATMIST: Age / sex - Time of incident – Mechanism – Injury - Signs and Symptoms / Ob's - Treatment given / time of arrival

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ASSESSMENT QUESTIONS / STRUCTURED PRF WRITE UP – MEDICAL MODEL