Patient Health Care Record SOP Version 4 - NSW · PDF filePatient Health Care Record SOP Version 4.0 ... DUTY OF CARE ... Ambulance Service of NSW Patient Health Care Records

Ambulance Service of NSW © Copyright SOP2009-025

Standard Operating Policy

Patient Health Care Record SOP Version 4.0

Document Number SOP2009-025

File No. 09/337 (D09/5282)

Date issued 22 June 2009

Author Branch Data Services

Branch contact 9320 7671

Division Finance & Data Services

Summary Instructions for the completion of Patient Health Care Records

(PHCR), Patient Transport Officer (PTO) PHCR, ECP form and ART cases of the Ambulance Service NSW.

Applies to (bold indicates

selection)

All Ambulance Service of NSW staff All Operational Staff All Administration staff All Headquarters staff Division staff (select Aero medical, Northern, Southern, Sydney, Western) Operations Centres (select All, Aero medical, Northern, Southern, Sydney, Western)

Review date 30 June 2010

Previous reference SOP2008-024

Status Active

Approved by Chief Executive

Compliance with this policy directive is mandatory.

PHCR SOP Version 4.0__________________________________________________________________ July 2009

Ambulance Service of NSW © Copyright SOP2009-025 Page 2 of 91

Table of Contents 1. EXECUTIVE SUMMARY..................................................................................................................... 4

2. DUTY OF CARE ................................................................................................................................. 5

3. MODIFICATIONS - JULY 2009........................................................................................................... 6 SUMMARY OF THE MODIFICATIONS TO THE PHCR FORM JULY 2009................................................................ 6

4. SPECIFIC OBJECTIVES .................................................................................................................. 10 Clinical ................................................................................................................................................ 10 Legal ................................................................................................................................................... 10 Administration/Business ...................................................................................................................... 10 Management of Information ................................................................................................................ 10

5. REGULATIONS ................................................................................................................................ 10

6. CRITERIA FOR RECORD COMPLETION........................................................................................ 11 A Patient Health Care Record is required for all patient contact and attendances:.............................. 11 A Patient Transport Officer Patient Health Care Record is required for: .............................................. 11 A PHCR or PTO-PHCR is not required under the following circumstances: ........................................ 11

7. GENERAL STANDARDS FOR DOCUMENTATION......................................................................... 12 A. Accuracy and Fact....................................................................................................................... 12 B. Completeness ............................................................................................................................. 12 C. Legibility and Correctness ........................................................................................................... 12 D. Objectivity.................................................................................................................................... 12 E. Timeliness ................................................................................................................................... 12 F. Abbreviation and symbol use....................................................................................................... 12 G. Signing the record ....................................................................................................................... 12 H. Documentation Auditing .............................................................................................................. 13 I. PHCR/PTO PHCR Copies........................................................................................................... 13 J. Retention and Disposal of soiled or damaged PHCRs. ............................................................... 14 K. Adding Information ...................................................................................................................... 14

8. INFORMATION PRIVACY ................................................................................................................ 15

9. SOP FOR PHCR COMPLETION ...................................................................................................... 17 9.1 GENERAL INFORMATION................................................................................................................. 17 9.2 PHCR INFORMATION..................................................................................................................... 18 9.3 PATIENT INFORMATION .................................................................................................................. 19 9.4 TRANSPORT INFORMATION............................................................................................................. 20 9.5 DISPOSITION................................................................................................................................. 21 9.6 EXEMPT........................................................................................................................................ 26 9.7 SUB CATEGORY ............................................................................................................................ 28 9.8 JOURNEY...................................................................................................................................... 29 9.9 TRANSPORT BYPASS ..................................................................................................................... 30 9.10 ESCORT, MRN, MEDICARE AND PENSION/CONCESSION................................................................... 31 9.11 TIMES........................................................................................................................................... 33 9.12 MAIN CONDITION/PROBLEM ........................................................................................................... 34 9.13 PATIENT/INCIDENT......................................................................................................................... 35 9.14 CURRENT MEDICATIONS ................................................................................................................ 36 9.15 ALLERGIES ................................................................................................................................... 37 9.16 VITALS ......................................................................................................................................... 38 9.17 TRAUMA/MEDICAL CONDITION........................................................................................................ 40 9.18 POSTURE ..................................................................................................................................... 41 9.19 ASSESSMENTS.............................................................................................................................. 42 9.20 INTERVENTIONS ............................................................................................................................ 43 9.21 AIRWAY ........................................................................................................................................ 44



9.22 O2 THERAPY ................................................................................................................................. 45 9.23 EQUIPMENT .................................................................................................................................. 46 9.24 CARDIAC MGT............................................................................................................................... 47 9.25 PROTOCOLS ................................................................................................................................. 48 9.26 TRAUMA TRIAGE CODES ................................................................................................................ 49 9.27 INCIDENT INFORMATION – COLLISIONS – VEHICLE DEFORMITY .......................................................... 50 9.28 RESCUE/SCAT DETAILS................................................................................................................ 51 9.29 OBSERVATIONS/DRUG AND FLUID TREATMENTS .............................................................................. 52 9.30 PHARMACOLOGY (CONTRAINDICATION AND CATEGORY)................................................................... 54 9.31 PATIENT ADVICE CARD AND REVIEWABLE DEATH............................................................................. 55 9.32 TRIAGE......................................................................................................................................... 56 9.34 PHCR SHEET ............................................................................................................................... 58 9.35 PRIMARY SURVEY ......................................................................................................................... 59 9.36 CARE/ECP.................................................................................................................................. 60 9.37 CARE EXCLUSIONS ...................................................................................................................... 61 9.38 CARE/ECP SCREENING ............................................................................................................... 62 9.39 CARE/ECP REFERRAL ................................................................................................................. 63 9.40 PATIENT TRANSPORT DECISION ..................................................................................................... 64 9.41 AMBULANCE SERVICE OF NSW – NON-TRANSPORT DECLARATION (P2)............................................ 65

10. SOP FOR PTO PHCR COMPLETION .............................................................................................. 66 10.1 GENERAL INFORMATION................................................................................................................. 66 10.2 PTO PHCR INFORMATION ............................................................................................................ 66 10.3 PTO PATIENT INFORMATION .......................................................................................................... 67 10.4 PTO TRANSPORT INFORMATION..................................................................................................... 68 10.5 PTO DISPOSITION......................................................................................................................... 68 10.6 PTO EXEMPT ............................................................................................................................... 69 10.7 PTO SUB CATEGORY .................................................................................................................... 69 10.8 PTO JOURNEY.............................................................................................................................. 69 10.9 PTO ESCORT ............................................................................................................................... 70 10.10 PTO MRN/MEDICARE/PENSION/CONCESSION NUMBER................................................................... 70 10.11 PTO MAIN CONDITION/PROB. ........................................................................................................ 71 10.12 PTO TIMES................................................................................................................................... 71 10.13 PTO REASON FOR TRANSPORT AND OBSERVATIONS ....................................................................... 72 10.14 PTO CURRENT MEDICATIONS, AGGRESSIVE PATIENT/INCIDENT, INTERVENTIONS REQUIRED, O2 THERAPY, RESEARCH................................................................................................................................ 73 10.15 PTO SIGNATURES........................................................................................................................ 74

11. SOP FOR ECP FORM COMPLETION.............................................................................................. 75

12. SOP FOR ART PHCR COMPLETION .............................................................................................. 82

13. REFERENCES.................................................................................................................................. 83

14. APPENDIX 1 – SUMMARY OF HEALTH PRIVACY PRINCIPLES .................................................. 83

15. GLOSSARY OF TERMS................................................................................................................... 85

16. INDEX ............................................................................................................................................... 90



Ambulance Service of NSW Patient Health Care Records

1. Executive Summary Changes relating to non-transport protocols effective from 1 July 2009 have had an important impact on the Patient Health Care Record (July 2009). The Disposition section of the form has had resultant changes which staff should ensure they are familiar with prior to commencement of the revised protocols. The introduction of the Primary Survey methodology and collection of the Worthing Score prompted the re-ordering of the Vitals section of the form as well as a new set of data fields to measure its efficacy. Other changes such as the recording of patient medications on scene, the addition of a check signature for drug administration and the addition of the intranasal skill set are included to support ambulance clinicians in their compliance with agreed practice. Additionally, the pilot ECP and CARE programs have seen further refinements which are reflected in changes to the PHCR form. As usual a summarised list of modifications to Standard Operating Policy is provided. It can be found on pages 6 to 10 of this document. This year, laminated posters of the PHCR and PTO PHCR forms highlighting the changes will be provided to each station. Crews working the night shift on 30th June 2009 should take both the July 2008 and July 2009 forms with them, changing to the new ones at midnight. Comments, questions and feedback on the new PHCR can be referred to PHCR [email protected]

Mick Willis General Manager Operations



2. Duty of Care

The duty of care is an important part of service delivery and is incorporated in the Service’s protocols, policies and procedures. To support and enhance the continuity of care, it is the responsibility of ambulance clinicians to ensure they provide and receive comprehensive clinical handovers wherever patient care changes from one clinician to another. This includes those occasions involving handovers to other health personnel (including ambulance Paramedics) and when receiving patients from others. Obligations also extend to maintaining an appropriate record of patient contacts where the patient is not transported or handed over to the care of another clinician. When receiving a clinical handover from hospital staff, ambulance Paramedics must ensure they understand all care requirements for patients during transport. If a Paramedic identifies any issue that may impact patient care such as the requirement for procedures outside their clinical level, they should alert hospital staff and the Operations Centre to the issue. These requirements are crucial components in ensuring the duty of care is appropriately discharged. Refer to Clinical Safety Information Improving Patient Safety and Clinical Quality CSI 13/07 May 2007.



3. Modifications - July 2009

Summary of the Modifications to the PHCR form July 2009

Throughout the SOP, from section 4.0 onwards, changes from the previous year are show in italics. PHCR SECTION DESCRIPTION REASON FOR

INCLUSION Page

1. Disposition New:

Addition of 4 options:

"Non-Tx Authorised Care-P1", "Non-Tx Healthy at Home-P3", "Non-Tx Other Agency-P6", "Non-Tx Non Health Issue-P7".

Change:

Renaming options:

"Trnspt Retrieval Teams" to "Tx Retrieval Teams".

"Non-Transport CARE-P5" to "Non-Tx CARE-P5".

"Non-Transport ECP" to "Non-Tx ECP".

"Station Casualty" to "Non-Tx Casualty Station-P8".

Rationale:

Reflect current Protocol's practice and terminology.

Page 21

2. Sub Category Remove:

option “NETS” from PHCR form

Rationale:

To be completed by ASNSW staffs when matched with NETS data.

Page 28

3. Patient / Incident New:

Add shadow-text “MISTO”

Rationale:

To guide Paramedic while writing the incident history in this order.

Page 35

4. Vitals New:

Add shadow-text “Primary Survey”

Add shadow-text “Minimum 2 Sets of Observations”

Darken the line on second set of Obs.

Change:

Rearrange order of Vitals.

Resize “MainCondition/problem” section.

Rationale:

Reflect "Primary Survey" practice and terminology.

To remind Paramedics fill in minimum of 2 sets of Obs.

To distinguish first 2 sets of Obs.

Reflect "Primary Survey" practice and terminology.

Page 38



PHCR SECTION DESCRIPTION REASON FOR INCLUSION

Page

5. Current Medications

New:

Addition option: "Meds with Pt on scene”.

Rationale:

To distinguish between Medication with Pt on scene and Medication Tx with Patient.

Page 36

6. Cardiac management

Remove:

Remove options: LX - Lifepak10, LV - Lifepak 5, HS - Heart Start 3000.

Change:

Simplifying options: L=Lifepaks, Z=ZOLL, A=AED

Rationale:

Compliance and reduce Data entry issues.

Match to current equipment.

Page 47

7. Protocols

(see Codes Sheet July2009)

New Protocol codes

Rename Protocol codes

Remove Protocol codes

Rationale:

Reflect current practice and terminology.

Page 48

8. Observations/Drug and Fluid Treatments

Change:

Increase font size of "Further Clinical Notes"

New:

Addition column “Signature”

Remove:

Remove dotted line

Rationale:

Improve visual and reflect current practice and terminology.

An administration check for issuing drugs and fluids to patient.


Page 52

9. Pharmacology


New Pharmacology

Rename Pharmacology

Remove Pharmacology

Rationale:


Page 54

10. Primary Survey New:

Addition options:

“Primary Survey A B C D E”,

“Worthing Score”,

“AMT Score”,

“Competency + Capacity / Demonstrate”.

Rationale:

The primary survey is current practice to enable the early recognition of illness in patients who may not be obviously unwell.

Page 59




Page

11. CARE/ECP Pathway.


New Pathway codes

Rename Pathway codes

Remove Pathway codes

Rationale:


Page 60

12. CARE Exclusion Remove:

Remove "CARE Exclusion" option boxes.

Change:

Combine usage of "CARE Pathway Red Flags", and naming as "CARE Exclusions".

New:

New Exclusion codes

(see CARE Resource Guide)

Rationale:

The name change and additional categories reflect current practice and terminology.

Page 61

13. CARE/ECP Screening

Change:

Rename option "Elderly Screen Performed" to "Elderly at Risk Screen", and the word "Screen" to "Result".

Rationale:


Page 62

14. Info Sheet Change:

Move "Info Sheet" and "Referral letter" to CARE column on PHCR, under section CARE/ECP Referral.

New:

Addition option “Triage”.

Rationale:

Re-grouping data fields to appropriate location.

Reflect Triage category given by the ER nurse for their patient

Page 63

Page 56

15. CARE/ECP Referral New:

Addition options: "Health Provider Feedback", "PHCR copy".

Rationale:


Additional categories reflect current practice and terminology.

Page 63




Page

16. CARE/ECP Referral Type/Outcome


Change:

Rename Title "CARE Referral" to "CARE / ECP Referral" on Backing sheet.

New:

Addition option "07 Not required".

Rationale:



Page 63

17. CARE/ECP Referral Type/Outcome


Change:

Rename options.

New:

Addition options.

Rationale:



Page 63

18. CARE/ECP Consent

Change:

Rename title "CARE/ECP Consent" to "Patient Transport Decision"

Rename heading "Consent to ECP and CARE Pathway" to "Consent to non-Transport".

New:

Add wording "Applies to P1, P3, P5, P7, P8, Non-Tx ECP".

Remove:

Remove the sentence "The Paramedics have provided me with a patient information sheet."

Rationale:


Reduces ambiguity of obtaining signatures from patients that are put into different non-transport protocols.

Page 64

19. Non-Transport Declaration

Change:

Rename title "Non-Transport Declaration" to "Non-Transport Declaration (P2)".

Rationale:

Reduces ambiguity of obtaining signatures from patients that are put into different non-transport protocols.

Page 65

20. Signatures New:

Addition option "IN" in skill section.

Rationale:

Additional options reflect current practice and terminology.

Page 57



4. Specific Objectives

Clinical

It is the responsibility of Paramedics and Patient Transport Officers to complete records pertaining to patient care. The overall patient information becomes an integral part of the hospital records, which on occasions influence treatment. All incidents must be recorded at the time of injury/illness or as near to that time as possible.

Legal

Patient care details are recorded on the PHCR, which is the official patient record for the Ambulance Service of NSW. As such, the PHCR may be called into account and subject to close scrutiny for any investigative purpose including evidence in a court of law. It is essential that forms are completed in a manner that meets the standards expected of all health and business records.

Administration/Business

The information is used to assess entitlements and financial charges that may apply for the particular service provided. Correctly completed PHCRs provide evidence toward gaining funding and maintaining current resources. Inaccurate records can cause distress to clients due to accounts being generated unnecessarily.

Management of Information

The PHCR has been designed to capture comprehensive (clinical history) and standardised (patient detail) data in the out of hospital setting. The information and data collected hold considerable value to numerous users.

The information obtained is used for reasons such as:

• Clinical governance • Service planning • Clinical skills research, i.e. Cardiac arrest survey • Funding submissions • Legal activities • Workforce planning

5. Regulations

The Service has a duty to satisfy legal and regulatory requirements of the following legislation and policies.

• Health Services Act 1997

• Ambulance Services Regulation 2000

• Ambulance Service of NSW – Standard Operating Policies – Sections: SOP2008-004 Patient Care; SOP2006-040 Completion of Shift; Student Training and Rights of Patients – SOP2007-115; Drug Management – SOP2008-014; Use, Care and Maintenance of Vehicles – SOP2007-051

• Protocols and Pharmacology 2009



• Health Records and Information Privacy Act 2002

• Poisons and Therapeutic Goods Act 1966

• State Records Act 1998

6. Criteria for Record Completion

A Patient Health Care Record is required for all patient contact and attendances: I. All cases where the Paramedic(s) have assessed and/or treated the patient even if the

patient has not been transported, (inclusive of Rapid Response Vehicle Paramedics);

II. All acute cases including admissions to hospital from a medical practitioner’s premises;

III. Inter-hospital/facility transfers even if treatment is not required from the Paramedic(s) and regardless of the presence of a nurse or other medical escort;

IV. All casualty cases; on station; standing-by at any incidents/events; Paramedics first on scene

V. All non transports following patient contact

VI. Assist load/unload, even if no treatment has been administered

VII. All cases where the Paramedics have arrived at the correct destination but the patient cannot be found or has left the scene (i.e. Unable to locate patient). This provides evidence of attendance at the incident and actions taken by the Paramedics.

VIII. All cases where a patient is already deceased prior to the Paramedics’ arrival.

A Patient Transport Officer Patient Health Care Record is required for: I. All instances of a patient transfer by Patient Transport Officer require completion of a PTO

PHCR. The PTO-PHCR form is NOT to be completed by Paramedics unless for a specific, pre-approved purpose.

A PHCR or PTO-PHCR is not required under the following circumstances:

• Media or public relations event;

• Resource relocation i.e. staff movement, vehicle movement, single Paramedic meeting another single Paramedic at scene and transporting in other vehicle.

• Case cancelled en route

• Vehicle has been reassigned to another case;

• Disaster/AMPLAN has been activated.



7. General Standards for Documentation

There are a number of mandatory requirements when completing the official records of the Ambulance Service of NSW.

A. Accuracy and Fact

Documentation must be as accurate and factual as possible. Paramedics need to distinguish between what they observe and what the patient states. An example of this is when a patient tells you they have been assaulted by a group of youths. This should be recorded as ‘The patient stated they were assaulted by a group of youths’ rather than ‘The patient was assaulted by a group of youths’, unless the Paramedic(s) actually witnessed the incident

B. Completeness

All documentation should give a clear, concise and complete account of the incident events or interaction with the patient. Any treatment, assessment or other details not recorded may be interpreted as though they did not occur if other evidence is not available.

C. Legibility and Correctness

It is essential that all documentation is legible and that all fields are recorded or marked correctly (see sections 9 and 10)

D. Objectivity

PHCRs must be written objectively and are not to include opinions or judgments. As a general rule opinions that are not supported by facts should be avoided. For example, the statement ‘the patient appears to be intoxicated’ should instead be recorded as, ‘the patient has slurred speech, an unsteady walk and their breath smells of alcohol’.

E. Timeliness

PHCRs should be completed on the same date and as close to the event as is practicable considering the operational requirements at the time. Records that are not completed until well after the event may lack in accuracy due to difficulty in recalling specifics of the incident/illness. In the event this occurs, a notation is recommended in the “Observations/Drug and Fluid Treatments” section of the PHCR stating the actual time the report was completed together with the circumstances of the delay. Please note PHCRs (originals) are to be submitted to the relevant Administration office as soon as possible after the incident date.

F. Abbreviation and symbol use

The only medical abbreviations to be used are those included in the SOP or the Codes Sheet.

G. Signing the record

It is a requirement that all Paramedics and medical nursing escorts sign a PHCR form for each incident attended. The signature is a declaration that a Paramedic attended an incident as well as a record of any treatment performed by the Paramedic or escort. Station Managers and/or their delegates must check that PHCR forms have been properly completed before signing the form.



H. Documentation Auditing

Station Managers and/or their delegates are responsible for auditing the report forms. Incomplete PHCRs and PTO PHCRs are to be returned to the attending Paramedics for immediate rectification. For any return, only return with “Blue” copy, “Pink” copy should be kept at Station. If PHCRs are not returned and on investigation are not able to be located they will be deemed “missing” and submission [to the relevant administration office] of the Medical Review or “Pink” copy will be required for processing in place of the original.

I. PHCR/PTO PHCR Copies All copies of PHCRs contain private information and care must be taken at all times to

maintain security of the records.

1. BLUE (Office copy) The “Blue” copy of the PHCR must be forwarded to your local Administration office for

capture into the PHCR System. The forms should be folded (not rolled or cut into two) and placed in envelopes or satchels to maintain privacy. Blue copies must never be used for medical review or other purposes.

2. PINK (Medical Review copy) Where required, the “Pink” copy of the PHCR must be sent to a designated Paramedic

for review. From 1 July 2009, and unless otherwise notified, the following reviews will be in effect:-

Medical Review Medical review officer PHCR Disposition: Non-Tx Authorised CARE –P1

Senior Medical Adviser, Rozelle

Cardiac Arrest Senior Medical Adviser, Rozelle Reviewable Death Manager, Patient Safety, Rozelle Variations to Clinical Practice Manager, Patient Safety, Rozelle ECP Advanced Clinical Care Project, RozelleCARE Advanced Clinical Care Project, Rozelle

All other pink copies should remain on station and be securely destroyed after 6 months.

3. GREY (Hospital/Patient copy) If the patient is transported to hospital the grey copy should be given to the hospital. If the patient is not transported to hospital, i.e. the PHCR relates to a non-transport (excluding CARE/ECP non-transport), standby or team transfer, the “Grey” copy should be retained at the station and destroyed after 6 months.

ECP/CARE The “Grey” copy will be given to the patient to facilitate transfer of patient care to another

health care provider, if needed.



J. Retention and Disposal of soiled or damaged PHCRs. If a PHCR form is soiled or damaged in a way that renders it unreadable or unsafe (an OH&S risk) the following applies:-

Soiled/Damaged PHCR form

Wherever possible remove all possible soiling and, if wet, allow to dry

Draw a line through all copies of the PHCR form (bottom LHS to top RHS)

Along the line explain why the PHCR is no longer useable (e.g. Contaminated with.., Torn with details missing etc.)

Above the pre-printed PHCR number, write:

“REPLACED BY [new PHCR number]” and write the date and time.

If contaminated, fold the PHCR form in half, printed side out, and place in a zip lock clear plastic bag (Stores item code 2150). Any torn sections should be secured together.

The soiled/damaged PHCR form should be stored with the station copies for 6 months then disposed of securely.

Replacement PHCR form On the replacement PHCR form, above the pre-printed PHCR number, write:

“REPLACES [old PHCR number]”, the reason for replacing the initial PHCR form and the date and time replaced

K. Adding Information

Changes can be made to the blue original PHCR/PTO PHCR copy, (once the copies have been separated) ONLY in the following sections: PHCR Information; Patient Information; Transport Information; Disposition; Times; and Signatures (including Paramedics names, signatures, employee numbers and levels.

Changes to the original PHCR/PTO PHCR copy can ONLY be made by: the Paramedics that attended the incident i.e. the Paramedics whose names are recorded in the “Signatures” section. Please note that changes/additions must be initialled and the date of the modification included beside the change(s) on the PHCR/PTO PHCR.

All late/additional information (clinical/other) for all other PHCR/PTO PHCR sections must be recorded in the Ambulance Service of NSW (NSW Health), Incident Information Management System (IIMS) available on the Service Intranet.



8. Information Privacy

Information collected by the Ambulance Service of NSW for completion of the PHCR is governed by the Health Records and Information Privacy Act (HRIP Act) 2002.

The purpose of the HRIP Act is to promote fair and responsible handling of personal health information. Personal health information is defined in the Act (Section 6) as “personal information that is information or an opinion about the physical or mental health or a disability (at any time) of an individual”. It is also concerned with an “individual’s express wishes about future provision of health services to him or her”. The health service provided or to be provided as well as any personal information collected is also considered personal health information for the purposes of the Act.

This definition encompasses the personal information collected on the PHCR, as well as the clinical information, which is the detail of the treatment provided to the individual. There are 15 Health Privacy Principles (HPPs) which can be categorised into collection, security, access and amendment, accuracy, use and disclosure principles (A summary of these principles is included as an Appendix on pg 83 - 84 section 13).

Compliance with these principles when completing a PHCR ensures that there are no breaches of the privacy legislation. The collection principles are designed to ensure that personal health information is collected only for a lawful purpose and that the purpose must be directly related to the business functions and activities of the Ambulance Service. When the information is collected it should be collected from the individual concerned (unless that is unreasonable or impractical) and the information should be relevant, accurate and not intrusive. Information should not be excessive. Once this information has been collected the individual (again if reasonable and practicable) should be made aware of how the information may be used, who may access it and the consequences of not providing it.

The office copy (blue original), which is sent for data entry and processing to divisional administration offices, is the official Ambulance Service of NSW copy. This copy will be retained and destroyed as per the General Retention and Disposal Schedule authorised by State Records. The Medical Review (Pink) copy must be kept secure to minimise loss, unauthorised use and misuse. The same safeguards must be made for the office copy. Particular care should be used when sending the PHCRs to administration offices for processing.

Patients can access the personal health information that the Ambulance Service holds about them. Individuals can find out what kind of information is held about them and what it is used for. Patients / clients may request that their personal health information be amended to ensure that it is accurate, relevant, up to date, complete and not misleading. Organisations must take relevant steps to ensure that the personal health information of a patient / client is relevant, up to date and not misleading. Care should be taken when completing the PHCR to ensure that the information collected is accurate. Part 7 General Standards for Documentation in the SOP also outlines the need for accuracy and completeness when completing PHCRs. The State Records Act 1998 also includes a legislative requirement for full and accurate records.

The HRIP Act governs the use and disclosure of health information. Health information can be disclosed for the primary and secondary purposes of collection and also if an act of legislation authorises the disclosure. An important issue when using or disclosing personal health information is to consider whether the patient has consented or if the use / disclosure is within the



reasonable expectations of the patient. The use and disclosure of personal information contained in a PHCR can be a breach of the Privacy Act if it is disclosed to unauthorised persons.

Individuals and organisations such as the Police, insurance companies and others, can make requests for the release of information through official channels. For media information release, Paramedics should refer to Ambulance Service of NSW, SOP2007-017- Media Policy. For PHCR/PTO PHCR and related information release refer to the Medical/Patient Records Unit at Rozelle.



9. SOP for PHCR Completion

9.1 General information

I. All alphabetical data (wording) is entered in CAPITAL/UPPERCASE, USE A BLACK BALLPOINT PEN ONLY. Press pen firmly.

II. All numerical data (numbers) is entered as LEFT Justified. This means all data is entered from left to right.

ENTER A DASH IN FIELDS CHARACTERISED BY CIRCLES. THESE MUST BE FILLED OUT AS ILLUSTRATED BELOW Circles = NOT or or III. Enter alphabetic or numerical characters in fields characterised by boxes: Boxes = A OR 4 IV. If an error occurs when marking the circle then: FOR NUMERICAL DATA:

♦ Place a cross through the error; ♦ Put your initials next to the error; ♦ Then mark the correct circle.

FOR ALPHABETICAL DATA:

♦ If the error is a word(s) then place a line through the word(s); ♦ Initial the error; ♦ Then write the correct entry.

Ensure all errors are legible. Liquid paper must not be used. VI PHCR/PTO PHCR VERSION

Date/version: ♦ Located in the lower right hand corner of the document is the month/year of release.

VII PHCR/PTO PHCR COPIES

Printed in triplicate

Refer to section 7 paragraph “I “on page 13.



9.2 PHCR Information

PHCR Field Always Mandatory Mandatory when

dictated by the circumstance

Responses

PHCR Number b Pre-Printed identification number Incident Number b 5-digit number Date (DD/MM/YY) b i.e. 010904 Patient of b Patient 1 of 1

Patient 2 of 3 Car Number b Responding car number Assist Car Number b if more than one car

in attendance Assist car number

Previous Transports b Y – Yes N - No U - Unknown

Incident Number - to be recorded when issued from CAD-MDT or MRU. Along with the date it identifies the specific incident.

Date – the correct date is crucial for incident identification.

Patient of - complete a separate PHCR for each patient. If one incident number is issued by CAD for a case requiring transport of multiple patients (3 patients for example) then record 1 of 3; 2 of 3; and 3 of 3 accordingly on each PHCR. If an incident number is issued for each patient on a multi-patient transport 1 of 1 should be completed on each PHCR/PTO PHCR. For obstetric cases, two separate records are to be completed - one for the mother and one for the baby or neonate.

Car Number - required for matching data from CAD as well as to report activity by station.

Assist Car – record the car number whenever another car is called to assist with loading a patient, assist with patient treatment, or assist to unload a patient. Note multiple assist car numbers in the “Patient/Incident History” section.



9.3 Patient Information

PHCR Field Always Mandatory Mandatory when dictated by the circumstance

Responses

Title b MR , MRS, MIS, MS, REV, SR, EST, BAB, MAS, DR

Patient Names (Family, Middle and Given)

b Write UNKNOWN if not

available

Name

Patient Address, (Town, Suburb and State)


available

Complete patient’s residential address (PO Box addresses are not acceptable)

Gender b F – Female M – Male U - Unknown

Date of Birth (DDMMYYYY)

b i.e. 01011944

Age b Age in whole years for older than 2 years and

whole months for younger than 2 years

Age

Interpreter Needed b if required complete if applicable in all circumstances

Language Spoken b if interpreter required

Indicate Language

Aboriginal or Torres Straight Islander

b when patient identifies as such

complete if applicable in all circumstances

Patient Phone Number


available

complete patient’s phone number

Title, Patient Family Name, Patient Given Name, Patient Middle Name - required to help identify the patient. If the full name of the patient cannot be obtained, UNKNOWN should be marked in the “Patient Family Name” field, and a notation attached explaining the efforts made to seek the information. The onus is on the attending officer(s) to acquire the patient details. The “Patient’s Title, Given Name and Date of Birth” must be obtained to assist correct invoicing and Patient Master Index matching. Information must be sought from the patient or their relatives/others.



Australian Aboriginal or Torres Strait Islander - these particulars are a national data item to be collected if possible. Paramedics should not put themselves at risk in gathering this information.

Interpreter needed – must be completed when required i.e. if any section is completed using another person to translate for the patient.

Patient Phone Number - If a contact number of the patient cannot be obtained, UNKNOWN should be marked in the “Patient’s Phone Number” field, and a notation attached explaining the efforts made to seek the information. Patients may be contacted by telephone by the ASNSW. Information must be sought from the patient or their relatives/others.

9.4 Transport Information


Responses

Patient Location (From) and Hospital Code

b Actual location address or if the location is identical to the patient address recorded above write “ADDRESS”

Destination Address (To) and Hospital Code

b If no transport occurs,

leave blank

Destination address

Patient Location (From) – designates the location that the patient is transported from. If this is the patient’s actual address (identical to the address noted in the Patient Information), write ‘ADDRESS’ ’ in this section. If the location is a designated hospital or a designated diagnostic service then the full institution/hospital name and the relevant code, (provided on the Codes Sheet) must be written in the space provided.

♦ If the actual patient location differs from the CAD location given, then the CAD coordinator must be advised.

Destination Address (To) – designates where the patient is transported to. If this is the patient’s home address write ‘ADDRESS’. If the destination is a designated hospital/diagnostic service, the full hospital/institution name and code (provided on the Codes Sheet) must be written in the space provided. There is no need to record post-codes, provided the state is noted.



9.5 Disposition


Responses

Disposition b One and only one of the

options MUST be selected

Select one Disposition: - Transported - Tx Retrieval Teams - Non-Tx Authorised Care-P1 - Transport declined/refused-P2 - Treatment decline/refused-P2 - Non-Tx Healthy at Home-P3 - Non-Tx CARE-P5 - Non-Tx ECP - Non-Tx Other Agency-P6 - Non-Tx Non Health Issue-P7 - Non-Tx Casualty Station-P8 - Deceased on Examination - Unable to Locate Patient - Assist Treat/Load - Operational Standby - Sporting/Special Event

(excludes major incidents and s44)

Any patient contact beyond an initial assessment is considered as treatment. Assessment is considered to be done when the Paramedic has completed the applicable parts of Procedure 104.1.

Transported – complete this field whenever a patient is transported and there is no Retrieval Team in attendance. This includes if a patient was deceased prior to the Paramedics’ arrival and is subsequently transported. If there is a Retrieval Team with a patient, use “Tx Retrieval Teams”. If the incident meets the criteria for a reviewable death, the “Reviewable Death” field must also be completed.

Tx Retrieval Teams – complete this field when a retrieval team is being transported or a patient is transported with a retrieval team. Non-Tx Authorised Care-P1 – use when a patient has a specific medical condition that requires pre-authorised medications or procedures not included in ASNSW Protocols and Pharmacology. The protocol number (P1) must also be written in the “Protocols” section. In the “Patient/Incident History” section of the PHCR, paramedics must describe in detail the nature and circumstance of the patient’s condition and why transport is not needed. Paramedics should send the PHCR Medical Review copy (Pink copy) and relevant documentation to the ASNSW Senior Medical Adviser. The “Consent to non-transport” portion on the PHCR must be signed.

Transport declined/refused-P2 - use in conjunction with the Non-Transport Patient/Carer Decline/Refuse Protocol (P2) when patient declines/refuses transport. A PHCR must still be completed to record the situation and actions taken by the attending Paramedics. In the



“Patient/Incident History” section of the PHCR, Paramedics must describe in detail the nature and circumstance of the patient’s condition and why transport is declined. Protocol (P2) must also be written in the “Protocol” section. Patient or carer should sign the “Non Transport Declaration” section on the PHCR or sign the “Non Transport Declaration” detachable portion on the Patient Advice Card. Paramedics should always complete and leave the Patient Advice Card with the patient/carer regardless of which section is signed i.e. “Non Transport Declaration” on the PHCR or “Non Transport Declaration” detachable portion on the Patient Advice Card and complete the “Pt. Advice Card” field. If the “Non Transport Declaration” detachable portion of the Patient Advice Card is signed, this must be stuck to the bottom right hand corner of the “Observations/Drug and Fluid Treatments” section.

Treatment declined/refused-P2 - use in conjunction with the Non-Transport Patient/Carer Decline/Refuse Protocol (P2) when a patient declines/refuses to be treated. A PHCR must still be completed to record the situation and actions taken by the attending Paramedics. In the “Patient/Incident History” section of the PHCR, Paramedics must describe in detail the nature and circumstance of the patient’s condition and why transport is declined. Protocol (P2) must also be written in the “Protocol” section. Patient or carer should sign the “Non Transport Declaration” section on the PHCR or sign the “Non Transport Declaration” detachable portion on the Patient Advice Card. Paramedics should always complete and leave the Patient Advice Card with the patient/carer regardless of which section is signed i.e. “Non Transport Declaration” on the PHCR or “Non Transport Declaration” detachable portion on the Patient Advice Card and complete the “Pt. Advice Card” field. If the “Non Transport Declaration” detachable portion of the Patient Advice Card is signed, this must be stuck to the bottom right hand corner of the “Observations/Drug and Fluid Treatments” section.

Non-Tx Healthy at Home-P3 – this only applies to Paramedics in an area where there is an HAH program. The protocol number (P3) must also be written in the “Protocols” section. In the “Patient/Incident History” section of the PHCR, paramedics must describe in detail the nature and circumstance of the patient’s condition and why transport is not needed. Paramedics should complete and leave a Patient Advice Card with the patient and complete the “Pt. Advice Card” field on the PHCR. The “Consent to non-transport” portion on the PHCR must be signed. Healthy at Home was previously known as SAFTE. Non-Tx CARE-P5 - This only applies to Paramedics who have successfully completed CARE training. Complete this field whenever a patient has given consent to enter into a non-Emergency Department pathway. Non-Tx ECP – This only applies to Paramedics who have successfully completed ECP training. Complete this field whenever a patient has given consent to enter into a non-Emergency Department pathway. Non-Tx Other Agency-P6 – use when access to the patient cannot be gained and the incident is in the control of another agency. The protocol number (P6) must also be written in the “Protocols” section. In the “Patient/Incident History” section of the PHCR, paramedics must describe in detail the nature and circumstance of the situation, the information given by the other agency and the advice they gave to the other agency. Details of the personnel that advised against access to the patient must be recorded on the PHCR. Non-Tx Non Health Issue-P7 – use when the patient does not have a health issue. The protocol number (P7) must also be written in the “Protocols” section. In the “Patient/Incident History” section of the PHCR, paramedics must describe in detail the primary survey and patient assessment that was done and revealed no health issue. The “Consent to non-transport” portion on the PHCR must be signed.



Non-Tx Casualty Station – this applies when a patient presents and is treated on site at a Casualty Station. The protocol number must (P8) also be written in the “Protocols” section. In the “Patient/Incident History” section of the PHCR, paramedics must describe in detail the nature and circumstance of the patient’s condition and why transport is not needed. Paramedics should complete and leave a Patient Advice Card with the patient and complete the “Pt. Advice Card” field on the PHCR. The “Consent to non-transport” portion on the PHCR must be signed.

Deceased on Examination – complete this field whenever the patient is deceased on arrival at scene and is not subsequently transported by ASNSW. If a deceased patient is transported, the “Transported” field should be completed instead. The “Reviewable Death” field does not need to be completed as the patient has died prior to ASNSW arrival.

Unable to Locate Patient – complete this field if patient is unable to be located at the scene. Record observations on arrival at the scene and the actions taken to locate the patient in the “Patient/Incident History” section. This may include comments by other parties at the scene (this differs from the CAD disposition “Unable to locate incident” in which the reported address cannot be found).

Assist Treat/Load - Record observations on arrival at the scene and the actions taken in relation to other units / services in attendance in the “Patient/Incident History” section. This provides evidence of attendance and the rationale for actions taken.



Operational Standby – complete this field when a crew is on standby.

1. Private Business – An industrial incident where hazards have or may occur, e.g. Chemical spill, factory fire.

The “Patient Information” section is to be completed with the name and address of the business responsible for the service. Record other attending services, e.g. fire brigade, police, SES and other information e.g. the name of attending company supervisor, in the “Patient/Incident History” section. In the Disposition section “Operational Standby” must be completed.

a. Patient treated but not transported on operational standby- A separate PHCR must be completed if a patient is treated at the scene of an operational standby, the patient details i.e. full name, address and DOB is to be completed in the “Patient Information” section. Paramedics will need to obtain a new incident number from CAD for each patient. “Operational Standby” must be completed in the Disposition section.

b. Patient transported on operational standby - A separate PHCR must be completed if a patient is transported by a vehicle on operational standby, the patient details i.e. full name, address and DOB is to be completed in the “Patient Information” section. Paramedics will need to obtain a new incident number from CAD for each patient. “Transported” must be completed in the Disposition section.

2. Emergency Services – Applies to NSW Fire Brigade, Rural Fire Services (RFS), NSW Police, Volunteer Rescue Association (VRA), NSW Corrective Services and State Emergency Services (SES) where an ambulance is requested for standby.

The “Patient Information” section is to be completed with the name of the service requesting the standby and the location of the incident. In the Disposition section “Operational Standby” must be completed.

a. Emergency worker treated but not transported on operational standby- A separate PHCR must be completed if an emergency worker is treated at the scene on operational standby, the emergency worker details i.e. full name, address and DOB is to be completed in the “Patient Information” section. Paramedics will need to obtain a new incident number from CAD for each patient. “Operational Standby” must be completed in the Disposition section and “Emergency Worker” must be completed in the Exempt section.

b. Emergency worker transported on operational standby- A separate PHCR must be completed if an emergency worker is transported by a vehicle on operational standby, the emergency worker details i.e. full name, address and DOB is to be completed in the “Patient Information” section. Paramedics will need to obtain a new incident number from CAD for each patient. “Transported” must be completed in the Disposition section and “Emergency Worker” must be completed in the Exempt section.



Sporting/Special Event

1. Attendance at Sporting or Special Event A PHCR must be completed for each vehicle attending a sporting event except those covered by a bulk agreement such as the one between the Sydney Division and the AJC. Complete “Sporting/Special Event” field in the “Disposition” section. In the “Patient Information” section – record the name and address (if known) of the Event Organiser. In the “Patient Location (From)” field – record location attended. In the “Destination Address (To)” field – record the nature of the event.

2. Patient Transported from a Sporting or Special Event Additional PHCRs must be completed for each patient transported from a Sporting or Special Event. A new incident number will need to be obtained from CAD for each PHCR that is completed.

3. Patient Treated but not Transported from a Sporting or Special Event Additional PHCRs must be completed for each patient treated at a Sporting or Special Event. A new incident number will need to be obtained from CAD for each PHCR that is completed. When scheduled to attend a special or sporting event, Paramedics must be advised if it is a commercial or non-commercial event by their sector office.

i. Commercial Events – Patients treated at commercial sporting or special events will not be charged for the service. Complete the “Sporting/Special Event” Disposition field.

ii. Non-Commercial Events – Ambulance attendance at non-commercial events will attract a “treat and not transport” charge for those patients who receive treatment on site but are not transported to a medical facility. Complete the PHCR as above, but record in the “Disposition” section as “Transport declined/refused-P2”.



9.6 Exempt



Responses

Exempt b whenever one of the exemptions occur

Select one Exempt: - Corrective Services - Emergency Worker - CR - Police Custody - SIDS - S/D Assault - Third Party

Corrective Services - complete this field if the patient is being transferred to or from a correctional institution. It is not to be completed if the patient is being transferred between two public hospitals.

Emergency Worker – complete this field if the patient is an emergency worker being treated on emergency standbys. Emergency worker applies to NSW Fire Brigade, Rural Fire Services (RFS), NSW Police, Volunteer Rescue Association (VRA), NSW Corrective Services and State Emergency Services (SES) where an ambulance is requested for standby.

CR (Child at Risk) – complete this field if the Paramedic believes that the issuing of an account to the family may result in further trauma being inflicted on the child, e.g. if a child has been assaulted by a family member. This does not replace the current procedure for “children at risk”. Refer to Standard Operating Policies and Procedures Manual CL1.32 and form 25.

Police Custody – complete this field if the patient is actually in police custody at the time of the incident. This does not apply to patients transported from a police station but are not actually in custody, e.g. an assault victim who has gone to a police station to report an incident and the police call and request ambulance assistance.

SIDS – complete this field for all cases involving the death of an infant between 0 – 2 years of age. An invoice will not be raised.

S/D Assault (Sexual or Domestic Assault) – complete this field if the patient is treated/transported as a result of a domestic or sexual assault. This prevents an invoice being raised.

Third Party: (NSW Registered Vehicle) – This applies to MVAs involving 2 or more vehicles – complete this field for all patients treated at or transported from the scene of a MVA involving two or more vehicles. The “Collisions” and “Vehicle Deformity” sections must also be completed.



General information

Minors – all accounts are raised in the name of the minor as per NSW Health Department procedures. The issue of Parent/Guardian is not the responsibility of the Service.

Private Health Insurance – accounts are raised against the patient. It is the patient’s responsibility to arrange confirmation from their insurer as to their current status of membership. This is done by either posting or presenting the account to the appropriate authority for stamping and then returning the account to the Service. It is not the Paramedic’s responsibility to collect this data.

Worker’s Compensation – accounts are raised against the patient. If the claim is accepted by the insurer the account may be paid directly to the Service. Alternatively payment will be required from the patient. It is not a Paramedic’s responsibility to collect this information.

Ambulance Employees and Immediate Family – Ambulance employees are not identified at the time the PHCR is received. They are billed as any other transport and the account written off once they have identified themselves through the process outlined on the back of the invoice, (ensure the patient’s employee number is noted on the PHCR). This is because many employees are privately insured which takes precedence over non-chargeable transports. This does not mean that the employee is at any stage responsible for payment of the account. It is to the advantage of the Service to manage the account in this manner as the Health Insurers pay a levy to Treasury for all insured persons. The levy is paid regardless of whether ambulance services are used.



9.7 Sub Category

PHCR Field Always Mandatory Mandatory when dictated

by the circumstance Responses

Sub Category b MVA Single Vehicle Overseas Tourist

MVA Single Vehicle – Complete this field if the patient is involved in a single motor vehicle accident. The “Collisions” and “Vehicle Deformity” sections must also be completed.

Overseas Tourist - Complete this field if the patient quotes an overseas address.



9.8 Journey


Responses

Journey b Single Return

Multistage b 1st 2nd Final

Single Journey – all journeys are “Single” unless they are return.

Return Journey – complete this field when a patient returns to their originating location with the same vehicle within a 24 hour period and that vehicle has not attended any other incidents in between. A separate PHCR must be completed for forward and return journey with separate CAD incident numbers and the “Return” box must be ticked.

Multistage - complete if a journey is part of a multistage transport. A separate PHCR must be completed for each stage. Multistage is used in conjunction with the PHCR Dispositions “Transported” and “Tx Retrieval Teams”.

If PHCR Disposition is Transported (i.e. no retrieval team)

1st Stage – complete this box for the initial leg of a multistage journey. This could be:

• Transporting a patient from a health facility to meet another ambulance at a point along the patient’s journey to a second facility.

• Transporting a patient from a scene to meet another ambulance en route.

2nd stage – Complete this box when transporting a patient for a leg of a journey which is neither the first leg nor the Final leg. This could be:

• Transporting a patient from one health facility or ambulance to another health facility or ambulance where the from location is not the commencing point of a journey and the To Destination is not the final Destination.

Final stage – Complete this box if this is the final leg of a patient’s journey. It could be:

• Transporting a patient from an ambulance or health facility en route to the final destination.



If the PHCR Disposition is Tx Retrieval Team:

1st stage (Team to Hospital) – Complete this box if transporting a team from their base location to the requesting hospital.

2nd stage (Patient to Hospital) – Complete this box if transporting a patient that is accompanied by a retrieval team to Hospital.

Final stage (Team to Base) – Complete this box if transporting a medical team that is returning to its home base.

9.9 Transport Bypass



Transport Bypass b Cardiac Mental Health Trauma Opt. Centre

Transport Bypass - This section is to be completed whenever the nearest hospital is bypassed in favour of a hospital better suited to treat the patient’s condition. If the nearest hospital is the appropriate one for the patient’s condition and the patient is transported there, do not complete this section.

Cardiac - ETAMI patients (Sydney only)

Mental Health - Use in conjunction with Protocol S3 Mental Health Emergencies (June 2006)

Trauma - Protocol T1 bypass to trauma or RP4 hospitals

Opt. Centre – Operations Centre dispatcher instructs the crew to bypass the nearest hospital.



9.10 Escort, MRN, Medicare and Pension/Concession



Escort b Complete if any escort travels in the vehicle with a patient for the purpose of the patient’s care/service.

Police Nurse MO (Medical Officer)

MRN/Authority b Enter the patient’s Medical Record Number or the Medical Officer’s name who is authorising the transfer

Number or Name

Medicare Number b If not available, leave

BLANK

10 Digits e.g. 1234 56789 0

Pension/Concession Number

b If not available, leave

BLANK

Aged Pension • 9 numbers + 1 alpha

DVA Pension • Use the “Service

Number” in the bottom right hand corner of the card.

DVA b Complete if pension number is DVA.

complete if applicable

If a nurse or medical officer is the key provider of clinical care to the patient they should complete their own clinical notes/record. Paramedics must still complete a PHCR and record this in the Patient History section.

When a nurse escort is requested to fill a shortfall in Ambulance staff, the Paramedic is deemed to be the clinical care provider and must complete the PHCR appropriately.

If a police officer, nurse or medical officer is transported with a patient, their signature must be obtained as confirmation of their attendance.

A relative or carer being transported with the patient is not considered an “Escort”. However the fact they are transported with the patient should be recorded in the Patient History section of the PHCR.



Medicare Number – it is important to obtain the patient’s Medicare number where possible as this is used to match the patient with previous transports.

Pension/Concession Number – complete this field if the patient is a holder of a pension/health care concession card. Leave BLANK if pension number not available. Ensure the card has not expired. If no pension number is available then this section should not be filled in. The patient will be invoiced but this will be written back when a valid pension number is subsequently provided.

Pensioner DVA (Department of Veteran Affairs) – complete this field if the patient is the holder of a DVA pension. Ensure the DVA card has not exceeded its expiry date. If no DVA pension number is available then this section should not be filled in. The patient may be invoiced but this will be written back when a valid pension number is subsequently provided.



9.11 Times

PHCR Field Always Mandatory

Mandatory when dictated by the circumstance

Responses

Booked b Time Scene b Time Patient Contact b Time Depart Scene b Time Triage b Time Off Stretcher b Time Odometer Beginning b Odometer End b

Include all six digits including leading zeros.

Pat. Sport Release b for trapped patients or time released from sporting standby

Time

All times are mandatory - all available times are to be recorded other than when officers are reassigned or the patient is not transported. Underlined times assist with checking/processing.

Times are for the purpose of core review. The time stamped in the CAD System is accepted as the true and correct record for the Service. This relates to all times that are recorded by CAD acknowledging that there will be differences in time intervals arising from implementation of new technology that will provide an electronic interface for the purposes of recording times.

Booked – is the time recorded when sufficient details for the incident are derived (i.e. location of incident and type of incident) and sent to dispatch for action.

Scene – is the time when an ambulance crew arrives at the location of a patient/incident.

Patient Contact – is the time when the first Paramedic makes contact with the patient. When a patient is inaccessible due to difficult access, this time will be later than the scene time.

Depart Scene – is the time when the ambulance crew departs the incident location and undertakes transport.

Triage – is the time the receiving hospital staff commenced triage/sorting/assessment of a patient brought in by ambulance.

Off Stretcher – is the time when a Paramedic transfers a patient onto a hospital bed and hands over the care of the patient to the Emergency Department.

Odometer Beginning and Odometer End – the vehicle odometer reading must be recorded at the commencement and completion of each case. All digits MUST be recorded including leading zeros to allow for accurate patient invoicing.

Pat. Sport Release – note this field has a dual role – it is either the time the patient, if trapped, is released from entrapment or confinement OR if a unit is on stand-by at a sporting or special event venue it is the time when that unit is released from attendance. This does not apply to patients



transported from a sporting or special event. It only applies to standby attendance to enable accurate invoicing.

9.12 Main Condition/Problem



Responses

Main Condition/Problem

b ONE field MUST BE COMPLETED

Est. time of Incident/Symptom

b if available and of clinical significance

Write time or N/A (Not Available) in field

Est. date of incident/symptom

b if available and of clinical significance

Write date or N/A (Not Available) in field

Main Condition/Problem – select the condition/problem that best describes the general pathophysiology grouping/circumstances of the patient. One field must be selected. The “Chief Protocol” section should reflect the specific protocol number for which the patient is being treated. If the patient is treated for other secondary conditions/symptoms, these should be reflected in the “Protocol” section.

Est. Time of Incident/Symptom & Est. Date of Incident/Symptom – these fields are intended to document the estimated time of a patient’s injury/illness onset. For example, a patient may complain of chest pain that began eight hours before a Paramedic’s arrival. Paramedics should ensure that the descriptions are accurate as often these details are of significant clinical importance for the patient’s ongoing treatment.

♦ If information regarding an estimate time/date of incident/symptom is not available, enter N/A (Not Available) in these fields and then record associated reasons in the “Patient/Incident History” section.



9.13 Patient/Incident



Responses

Chief Complaint b One line description reflecting the patient’s chief complaint.

Patient/Incident History

b Record past and present history

Paediatric Weight b must be recorded if interventions or drugs used

Kilograms/Grams

Temperature b as per thermometer reading Site b Tymp

Other

Chief Complaint - a brief description of the main patient complaint only requires a few words. The “Chief Complaint” must reflect what is recorded in the “Main Condition / Problem” section.

Patient/Incident History – describe in detail the nature and circumstances of the patient’s condition including the events that may have impacted on this condition. Also, outline incident details i.e. Standing-by at a bush-fire, or bomb threat. It is suggested that documentation include what Paramedics were called to (C/T), what was found on arrival (O/A), what was found on examination (O/E), and a history (Hx) describing the events surrounding the illness/injury/incident. If there is not enough space to detail the history, the Comments section located in the Drugs & Fluids Treatment part of the form can be used. Paramedics must explain the reason in the “Patient/Incident History” when any non-transport protocol is used.

Paediatric Weight – recorded as either an estimate or from factual information given by a parent/guardian. If interventions/drugs are used then a child’s weight must be recorded.

Temperature – record the thermometer reading.

Site - complete “Tymp” field if tympanic temperature taken or in “Other” field define the site.

MISTO - Information that should be recorded in the Patient/incident section of the PHCR i.e. Mechanism of Injury, Injuries, Signs and symptoms, Transport, Other.



9.14 Current Medications


Responses

Current Medications b Patient on Meds. Yes, No, Unknown Meds. with Pt. on scene Yes, No. Meds. Transport with Pt. Yes (list specific medications), No

Current Medications – is to be completed as per information provided by the patient/relative/other. If there is no information provided by the patient/relative/other, complete “Unknown” field.



9.15 Allergies


Responses

Allergies b Nil Unknown Yes (list specific allergies)

Allergies – is to be completed as per information provided by the patient/relative/other. If there is no information provided by the patient/relative/other, complete “Unknown” field.



9.16 Vitals



Responses

Time b Time Respiratory Rate b Rate per minute Effort b 0 - Unsatisfactory

1 - Satisfactory Breath Sounds b N – Normal

C – Crackles W – Wheezes X – Absent D - Decrease

SpO2 %(Oxygen Saturation Level)

b Add suffix if reading is taken whilst the patient is breathing: O = Oxygen or R = Room Air

Pulse b Rate per minute Systolic b Blood Pressure reading Diastolic b Blood Pressure reading GCS – Eye Opening b 4 – Spontaneous

3 – To Voice 2 – To Pain 1 – Nil

GCS – Verbal b 5 – Oriented 4 – Confused 3 – Inappropriate 2 – Incoherent 1 – Nil

GCS – Motor b 6 – Obeys 5 – Localises 4 – Withdraws 3 – Flexion 2 – Extension 1 – Nil

APVU b A – Alert P – Painful Stimuli V – Verbal U – Unresponsive

Pupil Size b - Dilated

- Normal i - Constricted




Responses

Pupil Reaction b > Larger < Smaller = Equal To ≠ Unequal + Reactive – Non-Reactive

Blood Glucose Level (BGL)

b BGL according to glucometer or glucose stick reading.

Pain Score b 00 = No pain; up to 10 = Worst pain imaginable

PEFR L/Min b 3 char alpha ETCO2 b Numeric

The order of collection of the patient vital signs reflects that of the Primary Survey.

Number of Vital Observations- a minimum of two sets of observations is required. If no observations are recorded an explanation is required in the “Patient/Incident History” section of the PHCR.

SPO2 % (Oxygen Saturation Level) – record the saturation of oxygen in the patient’s blood according to the pulse-oximeter reading. Also record whether the patient was breathing oxygen (O) or room air (R) when the reading was taken.

Glasgow Coma Score – read from left to right, EYE, VERBAL, MOTOR and TOTAL e.g. .Eye = 4; Verbal = 5; and Motor = 6 with a total Glasgow Coma Score of = 15. Please note neonate “APGAR” scores must NOT to be placed in the GCS section. These scores should be recorded in the “Patient/Incident History” section.

Indication for pain score completion – complete as part of clinical assessment only when determining patient’s subjective level of pain or discomfort for age 6 years and older. If possible, ask the patient to rate their level of pain between 0 and 10: 00 = No pain; up to 10 = the worst pain imaginable. PEFR L/Min -This only applies to Paramedics who have successfully completed CARE or ECP training. Complete this field to record the peak expiratory flow rate of the patients forced expiration in litres/second and is an objective measure of airway narrowing.

ETCO2 – This only applies to Paramedics who have successfully completed CARE or ECP training. Complete this field where ETCO2 has been measured.



9.17 Trauma/Medical Condition


Responses

Trauma/Medical Condition

b As required – including trauma patients and patients with pain of any type.

Mark areas - As listed on PHCR form

Trauma/Medical Condition – use the schematic representation of the patient to indicate the areas where pain or trauma are present. The abbreviations are to be used to indicate the relevant feature. Significant localised medical signs/symptoms or descriptions can be noted i.e. severe, abdominal pain secondary to a dissecting aortic aneurism. ‘Dermatone’ regions have also been included.



9.18 Posture


Responses

Posture On Scene b

Posture Enroute b

Record according to codes: SU Supine PR Prone SI Sitting HE Head Elevated FE Feet Elevated LL Left Lateral RL Right Lateral SS Semi-Sitting SK Supine with knees flexed OP Other Posture

Posture On Scene - record the posture the patient was found in by Paramedics on arrival at scene.

Posture Enroute – record the posture the patient is placed in on scene, (patient location) during treatment and/or en-route to hospital/facility.

♦ If other posture (OP) is completed the actual patient posture/position should be recorded in the Patient/Incident History section.



9.19 Assessments


Responses

Airway b Clear Obstructed

Breathing b Present Absent

Palpable Pulse b Radial Absent Central

Central Perfusion b Pink Blue Pale

Clammy Skin b Absent Present

Blood Loss b as required Record in ‘milliliters’ Aggressive Patient b as required Scene

Final Mental Health Assessment

b as required Scene Final

Assessment - patient assessments conducted at two times – one at scene (S) and one at hand-over (F). It is important to provide as much detail as possible in all cases regarding a patient’s condition both on arrival at scene and at final assessment.

Clammy Skin – record if patient’s skin is clammy (with perspiration) to touch.

Aggressive Patient/Incident - this field is to be completed if actual or potential hazards are present. The procedure that must be followed for reporting these incidents is outlined in the IIMS a Guide to Notification of Incidents (ASNSW).

Mental Health Assessment – complete this field if the patient displays any of the behaviours/symptoms described in the “Pre-Hospital Mental Health Assessment” and “Suicide Risk Assessment” in Protocol S3 Mental Health Emergency.



9.20 Interventions



Responses

Interventions: Cervical Collar Chest Thrusts ECM IPPV Tension Pneumo Decomp

b whenever initiated complete if applicable in all circumstances

Intramuscular Injections

b whenever IM injection administered


Art. Tourniquet Time b whenever Arterial Tourniquet applied


Time b whenever Arterial Tourniquet applied

Time

Intraosseous

b whenever initiated complete if applicable in all circumstances

Unsuccessful b if Intraosseous unsuccessful


Intravenous Cannula Size

b whenever initiated Numbers

Unsuccessful b if unsuccessful complete if applicable in all circumstances

Infusion Site b whenever administered

Record L (Left) or R (Right) in left-hand column followed by: H Hand FA Forearm F Foot LL Lower Leg J Jugular CF Cubital-Fossa 0 Other

Number of all IV Attempts

b whenever attempted/placed in situ

Number

Mech Restraints b complete if applicable in all circumstances



Interventions - all interventions used are to be recorded. If applying an arterial tourniquet the time must also be recorded.

Infusion Site – record the location of the site of infusion (not the route i.e. I.M.). Note right or left limbs as R or L respectively in the LEFT HAND SQUARE, before the intravenous site code (i.e. RCF = Right Cubital-Fossa).

♦ Record the number of ALL intravenous cannulation attempts, whether successful or unsuccessful.

Mech Restraints – complete this field if any mechanical restraint is used on the patient.

9.21 Airway


Responses

Manual Position b as required Suction b as required Oral Airway b as required Nasal Airway b as required Laryngeal Mask Airway

b as required

Nasogastric Tube b as required Endotracheal b as required

Successful or Unsuccessful

Endotrachael Tube Size

b as required Millimeters

CO2 Detector b as required complete if applicable

Airway – indicates the particular intervention was successful (S) or unsuccessful (U).

Manual Position – refers to manual management such as head tilt/jaw thrust to maintain patency instead of the utilisation of airway management adjuncts.

Laryngeal Mask Airway (LMA) – The LMA is to be recorded when utilised.

CO2 Detector – Record if a CO2 detector is used in conjunction with intubation.



9.22 O2 Therapy


Responses

High Concentration Mask

b as required High Low

Non-Rebreather b as required complete if applicable in all circumstances

100% b as required complete if applicable in all circumstances

Nebuliser b as required complete if applicable in all circumstances

Nasal Prongs b Whenever nasal prongs supplied to patient by hospital / facility.


Nasal Prongs - are not supplied by the Service. This field is noted if a request is made by the medical staff from the transferring hospital/facility and the nasal prongs are supplied to the patient by the hospital/facility.



9.23 Equipment


Responses

Equipment b whenever utilized complete if applicable in all circumstances: Spine Scoop ED Splints

Spine – complete this field when this rigid board is utilised for extrication and transfer of a patient to a stretcher.

Scoop – complete this field when a stretcher that splits at the centre is utilised to scoop under a patient for extrication and transfer to another stretcher.

ED (Extrication Device) – complete this field whenever an extrications device (i.e. RED/KED/Other) is utilised in patient/spinal management.

Splints – complete this field when rigid material/device is placed on patients with suspected fractured limbs and utilised to minimise movement.



9.24 Cardiac Mgt.


Responses

Witnessed by Public b cardiac arrest Witnessed by Paramedics b cardiac arrest

Select either Public or A/O, if witnessed.

CPR Prior to Arrival b cardiac arrest complete if applicable CPR Paramedics b cardiac arrest complete if applicable Number of shocks prior to your arrival

b cardiac arrest Total number of shocks administered

O/Defib. b cardiac arrest Defibrillation other than employees of the Ambulance Service of NSW

Time of First Shock b cardiac arrest Time of first DC shock administered Initial ECG Rhythm b Suspected

Myocardial Ischemia/Infarction and Cardiac Arrest

See Table above “ECG Abbreviations”

ECG rhythm on arrival at hospital

b Suspected Myocardial Ischemia/Infarction and Cardiac Arrest

See Table above “ECG Abbreviations”

Mon./Defibrillator Machine b cardiac arrest ECG monitored patients

L – Lifepak Z – Zoll A – AED/Trial

Total Shocks b cardiac arrest Total number administered ROSC on arrival at hospital

b cardiac arrest Yes No

Deceased in Emergency Dept

b cardiac arrest complete if applicable

ECG transmitted to ED b Suspected Myocardial Ischemia/Infarction and Cardiac Arrest


ECG attach to Hospital Copy

b Suspected Myocardial Ischemia/Infarction and Cardiac Arrest


ECG ABBREVIATIONS Asystole ASY Electro-Mechanical disassociation EMD Idioventricular Rhythm I VR Pacemaker Rhythm PR Multiple Dysrythmias MD Sinus Rhythm SR ST – elevation myocardial infarction STMI Supra Ventricular Tachycardia SVT Ventricular Fibrillation VF Ventricular Tachycardia VT



CPR A/O – complete this field when attending Paramedics commenced CPR on the patient.

Number of shocks prior to your arrival - refers to any individual or Paramedic administering treatment before further intervention by the Paramedics listed in “Signatures” section.

O/Defib. (Other Defibrillation) – Complete this field when persons (such as the general public/other agency), other than those in the employ of the Service, defibrillate a patient.

Initial ECG rhythm and ECG rhythm on arrival at hospital – record an entry in these fields whenever a patient’s ECG is monitored.

Mon./Defib. Machine (Monitor/Defibrillator) – record the type of machine used to perform ECG monitoring and/or Defibrillation.

ECG transmitted to ED – complete this field when a 12 lead ECG has been electronically transmitted to a hospital.

ECG attach to Hospital copy – complete this field to record that an ECG strip for the patient has been given to hospital staff.

9.25 Protocols


Responses

Chief Protocol b Reflects the patient’s chief complaint

Protocols b Related protocols

Chief Protocol (Number “1” box) – record the main protocol utilised that best reflects the patient’s chief complaint and/or main condition/problem treatment. Record according to the standard current Service protocol numbers.

Protocols (Number “2-7” box) – record other related protocols, that may apply subsequent to the chief protocol. Record according to the standard current Service protocol numbers.



9.26 Trauma Triage Codes


Responses

Trauma Triage Codes b The case is identified as a major

trauma

2 digit code – refer to Backing Sheet

Trauma Triage Codes (Number “1-3” box) – Record the 2 digit Trauma Triage Codes that correspond to the criteria listed in the Trauma Triage Tool (MIST).

The Trauma codes reflect the criteria that identified the incident as a major trauma incident. Paramedics should record the main codes (criteria) that identified the case as a major trauma.

Paramedics can record up to 3 relevant codes in this field. Every major trauma should have a minimum of one code recorded. If more than 3 criteria of the triage tool are met, the main codes should be prioritised and recorded.



9.27 Incident Information – Collisions – Vehicle Deformity



Responses

Collision Vehicle Diagram

b All motor vehicle/ other collisions

X Position of Patient > Point of Impact

Collision Patient b All motor vehicle/ other collisions

Collision Safety Devices

b All motor vehicle/ other collisions

Vehicle Deformity b All motor vehicle/ other collisions

complete in the appropriate circle

Est. Impact Speed b All motor vehicle/ other collisions

High >60km/h Medium 30-60km/h Low <30km/h

The Service provides data regarding road crash victims and inputs/outcomes of collisions. The collection of this data greatly assists in planning for prevention strategies and seeking revenue for the Service.

Vehicle Diagram – record the position of patient (X) in the motor vehicle crash and point of impact (>) as observed at the scene. The diagram is not to be shaded.

Vehicle Deformity - complete the fields from observations at the scene.

Death in same vehicle – If another victim is deceased in the vehicle that your patient was travelling in, this section is to be marked.

Ejected – If the patient you are treating has been thrown from the vehicle they were travelling in at the time of the crash, this section is to be marked.

Trapped – If the patient you are treating is/was trapped in the vehicle either by confinement or compression, this section is to be marked.

Note: More than one option could be marked.

Estimated Impact Speed - the estimated impact speed is a guide to help assess the effect of the collision on the patient. This estimation should be made using the evidence available at the time, i.e. Damage to the vehicle and statement(s) made by occupant(s) regarding the impact speed.



9.28 Rescue/SCAT Details


Responses

Rescue Type b All rescues As listed on PHCR form Primary Role

b All rescues

Secondary Role b All rescues

Select either Primary or Secondary according to rescue designation.

SOO Number b All rescues 5 Number

Rescue Details – it is important to collect data to determine service needs. Record the type of incident and whether the rescue role is primary or secondary. This section is to be completed by Service Rescue or Special Casualty Access Team trained officers.

SOO (Rescue) Incident Number – record the specific rescue number issued for each rescue incident.



9.29 Observations/Drug and Fluid Treatments


Responses

Time b for all administered drugs and fluids

Rhythm b for all ECG monitored patients

Observations/Drug and Fluid Treatments

b for all observations, administered drugs and fluid treatments

Dose mcg/mg/G/mL b for all administered drugs and fluids

Route b for all administered drugs and fluids

Shock b for all administered defibrillation

Response b for all administered treatment

According to treatment administered and responses include initial and final observations

Signature b for all administered drugs and fluids

Obtain a signature by the cross-checker before administering a drug

Each treatment/administration - must be recorded in this field against the time of the intervention. DC shocks followed by intravenous therapy can be recorded on the same line if the time interval is within three minutes, i.e. in the case of cardiac arrest with ventricular fibrillation. Where applicable the effectiveness of the treatment should be indicated.

♦ ALL drugs (pharmacology) administered MUST be recorded, (Section 17, Regulations Part 3, Paragraph (10, Section (g) of the Poisons and Therapeutic Goods Act 1966, NSW) and Drug Management – SOP2008-014



Time – recording the time of administration of each pharmacology/fluid and/or DC shock/other treatment is required in this field.

Rhythm – refer instructions below for “EGC printouts”

Observations - where a patient’s heart rhythm is monitored via electrocardiograph, whether defibrillation occurs or not, the “Mon./Defib” field (Monitor/Defibrillation) in the Cardiac Arrest/Management Data section must be completed indicating the type of ECG machine utilised. Refer to the Codes Sheet 2009 or page 47 of the SOP for codes/abbreviations.

Drug and Fluid Treatments – the full name (no abbreviations) of the pharmacology must be written. Generic or trade names are acceptable.

Dose – indicate the appropriate dose volume or weight, either micrograms, milligrams, Grams, millilitres or litres.

Route – ensure the route of the drug administration appears in this section i.e. IM (Intramuscular); IV (Intravenous); SL (Sublingual); O (Oral); INHAL (Inhalation); INTRA (Intranasal).

Shock – record in Joules. The type of defibrillator used is required in the Cardiac Arrest Data section. Refer to the Codes Sheet 2008 for codes/abbreviations.

Signature – a cross-check procedure must be undertaken before administering any drug to a patient. The checker must then sign on the PHCR next to the checked drug.

ECG printouts - ONE is to be stapled to the PHCR Hospital copy (Grey); and ONE stapled to the Medical Review copy (Pink), both on the top right edge of the PHCR. It is important to label ECGs with the patient’s name, incident number and date of attendance in case the ECG is separated from the PHCR.

Further clinical notes – record other relevant information i.e. persons, agencies or vehicles on scene with patient prior to ambulance arrival.

♦ Clinical Risk Advice Line – provided for use by Paramedics only for guidance regarding clinical risk concerns call: 0428 238 423, (or 0428 ADVICE).



9.30 Pharmacology (Contraindication and Category)


Responses

Pharmacology b for all drugs or fluids administered

Current pharmacologies only refer to Codes Sheet 2009

Pharmacology Effective

b if drugs or fluids administered are effective, place dash in circle.


Contraindication b for all drugs or fluids contraindicated

Record appropriate current pharmacology number

Category b for all drugs or fluids contraindicated

1 = Vitals – i.e. BP/Pulse low 2 = Medical – i.e. Allergy or Reactive Tendency or Medical Condition

Pharmacology – record the identification numbers for all drugs/pharmacology administered as listed in the current Service “Protocols and Pharmacology” manual.

Effective – record if the drug/pharmacology was effective as determined by the administering Paramedic.

Contraindication – record all drugs/pharmacology identification numbers if determined as “contraindicated” as listed to the Ambulance Service of NSW “Protocol and Pharmacology” manual.

Cat. (Category) – record the category of rationale why the drug/pharmacology was not administered: 1 = Vitals – such as systolic blood pressure too low 2 = Medical – such as an allergy/reactive tendency/medical condition



9.31 Patient Advice Card and Reviewable Death


Responses

Pt. Advice Card b whenever a patient advice card is given to the patient/carer


Reviewable Death b complete if applicable

Pt. Advice Card – used in conjunction with Protocol (P2) Non-Transport when patient decline/refused transport or treatment. Paramedics should always complete and leave the Patient Advice Card with the patient/carer regardless of which section is signed i.e. “Non Transport Declaration” on the PHCR or “Non Transport Declaration” detachable portion on the Patient Advice Card and complete the “Pt. Advice Card” field. If the “Non Transport Declaration” detachable portion of the Patient Advice Card is signed, this must be stuck to the bottom right hand corner of the “Observations/Drug and Fluid Treatments” section. Protocol (P2) must be written in the “Protocol” section.

Given to Patient

Stick on to the Bottom right hand Corner of the PHCR

Example of Patient Advice Card



Reviewable Death - NSW Health has set performance measures for NSW Area Health Services and the Ambulance Service of NSW which include establishing a system to review all deaths within 45 days of the event. For the Ambulance Service, “Reviewable Deaths” are cardiac arrests in our care. The Clinical Review Group reviews cases that have ‘witnessed cardiac arrest’ and ‘reviewable death’ ticked on the PHCR. The PHCR should be forward as soon as possible to ensure that these cases are reviewed within 45 days of the incident. The PHCR can be forwarded via internal mail to; Clinical Review C/- Clinical Development Or scan a copy of the PHCR and email to [email protected]

9.32 Triage


Responses

Triage bwhen given by triage nurse

1digit score: 1 - 5

Triage: one digit score between 1 and 5. This is an area where paramedics can record the triage category given by the ER nurse for their patient.



9.33 Signatures – Skills List and Research


Responses

Driving Officer Name / Signature / Employee Number / Level

b Name Signature Employee Number and level

Treating Officer Name / Signature / Employee Number / Level

b Name Signature Employee Number and training level

Third Officer / Escort/Other Officer Name / Signature / Employee Number / Level

b Including escorts and other treating officers, such as nurses, First Responders, Honorary Paramedics.

Report Checked By Station Officer/ Delegate Name / Station Name Signature / Employee Number / Level

b Print name Print Station NAME, not Station Number Signature Employee Number Training level

Skills List b when skills performed

complete if applicable - skills administered per officer name

Research b when advised by instructional circular

As advised

Signatures (Officer Name, Officer Signature, Officer Employee No. and Level) – Paramedics must clearly write their name and sign the PHCR as a record of attending the case. The employee number and level of training (i.e. 5 or 4) are to be noted. Any interventions performed by a Paramedic are to be noted in the Skills list, (refer to SOP OP1.53).

Third Officer/Escort/Other – any third person (Medical Officer, Nurse, Student, and Police Officer) or Paramedic/Patient Transport Officer involved in the treatment/transport of a patient and actually transported to the destination address are required to complete this field. Escort field should also be completed (refer to Section 9.10 on page 31)



Report Checked by SO/Delegate – all PHCRs/PTO PHCRs must be checked for accuracy and completeness by the Station Manager and/or their delegate before submission to administration offices. The checking officer is to print their name, station, level, employee number and include their signature in this section. Refer to section 7 General Standards for Documentation (paragraph “K”, “Adding Information”, page 14) of the SOP for further information on making changes to the PHCR after the copies have been separated.

Station - the Station recorded on the PHCR designates where the station copy will be retained for quality assurance follow up. The STATION NAME (not station number) must be clearly printed next to the name and signature of the checking officer.

Skills List – record interventions performed next to the appropriate administering officer’s name.

Research - completion of the Research section will take place as advised. Such activities periodically take place using these fields to record patient related data.

9.34 PHCR sheet


Responses

ECP bwhen PHCR ECP form attached


PHT bwhen PHCR PHT form is attached


PHCR Sheet of bwhen additional PHCRs is used

i.e. PHCR Sheet 1 of 3 PHCR Sheet 2 of 3

ECP - complete this field if a PHCR Extend Care Paramedic (ECP) form is attached.

PHT - complete this field if a PHCR Pre-Hospital Thrombolysis (PHT) form is attached.

PHCR Sheet of - complete this field whenever a PHCR is a continuation of the other PHCR e.g. 1 of 3; 2 of 3; and 3 of 3 accordingly on each PHCR or if a supplementary sheet has been completed by an ECP Paramedic.



9.35 Primary Survey


Responses

POS / NEG b Complete Positive or Negative Circle options (A,B,C,D,E)

Worthing Score b 2 digits score: 00 - 14 AMT Score b 2 digits score: 00 - 10 Competency + Capacity demonstrated

b YES NO

Primary Survey: - This survey must be done for all patients. If survey is positive, patient can not be offered a non-transport pathway. Worthing Score: – The Worthing Physiological Scoring System provides a score for a patient based on respiratory rate, pulse rate, systolic BP, temperature, SpO2 room air and AVPU. If score is greater than 1 then patient cannot be offered non-transport. (max score is 14 so two digit score can be from 00 to 14) A.M.T Score: – Hodkinson Abbreviated Mental Test. Patient is asked 10 questions and scores 1 mark for each correct response. A score of less than 8 suggests cognitive impairment and the inability to make a non-transport decision. (Two digit score can only be 00 – 10) Competency & capacity demonstrated: – Paramedic must demonstrate that patient can receive, believe, retain and explain information to determine that they have the capacity to make a non-transport decision.



Section 9.36 – 9.39 only applies to Paramedics who have successfully completed CARE or ECP training.

9.36 CARE/ECP


Responses

Pathway bFor all identified CARE clinical pathways

2 digit code

CARE Disposition b For all identified CARE clinical pathways

2 digit code

Pathway – Record the 2 digit CARE/ECP Pathway code that corresponds to the patient’s condition/presentation. CARE Disposition – Record the 2 digit CARE Disposition code that corresponds to the category of care provided to the patient.



9.37 CARE Exclusions


Responses

CARE Exclusions bFor cases where exclusions are

identified

4 digits code – refer to CARE Resource Guide

CARE Exclusions – For patients who are identified for a CARE Pathway and who present with one or more generic or pathway specific exclusions, record the 4-digit CARE code(s) that precludes the patient from non-ED care. Up to six exclusions can be recorded.



9.38 CARE/ECP Screening


Responses

Elderly at Risk Screen bFor cases where the patient is 65 years or

older

Complete “YES” or “NO”

Result bFor cases where the patient is 65 years or

older

Complete “Positive” or “Negative”

Elderly at Risk Screen – Patients 65 years of age and older should be screened using the Elderly at Risk (EAR) Screen. Complete “Yes” if the screen is performed, complete “No” if the screen is not performed. Result – Complete “Positive” if the patient scores positive on the screen, complete “Negative” if the patient scores negative.



9.39 CARE/ECP Referral


Responses

Referral attempted bFor cases where a referral has been

attempted

Complete “YES” or “NO”

Type/Outcome bFor cases where a referral has been

attempted

2 digit code for type 1 digit code for outcome

Pt. Info sheet bwhen given to patient complete if applicable Referral letter (ECP) b when given to patient complete if applicable Health Provider Feedback

b when given to patient complete if applicable

PHCR copy b when given to patient complete if applicable

Referral attempted – Complete “Yes” if a referral is attempted, complete “No” if a referral is not attempted. Type/Outcome – In cases where a referral is attempted, the outcome of that attempt is to be recorded. Refer to the Codes Sheet 2009 for the Outcome Code.

Pt. Info sheet – Complete this field if an information sheet has been given to the patient/guardian/carer.

Referral letter (ECP) – Complete this field if a referral letter has been given to the patient/guardian/carer.

Health Provider Feedback – Complete this field if a Health Provider Feedback Form has been given to the patient/guardian/carer.

PHCR copy – Complete this field if a copy of the PHCR has been given to the patient/guardian/carer.



9.40 Patient Transport Decision


Responses

Patient/Guardian/ Carer and DATE

bFor cases where patient consents to

non-ED care

- Obtain signature of patient/guardian/carer agreeing to non-ED care. - Record date dd/mm/yy

Patient/Guardian/Carer and DATE– The patient, carer or guardian who opts for non-ED care must sign the consent statement.



9.41 Ambulance Service of NSW – Non-Transport Declaration (P2)


Responses

Ambulance Service of NSW Non-Transport Declaration

b to be signed by patient/other when treatment/transport is refused

Patient/Other Signature Time of signature Witness name, signature and address if possible

Non-Transport Declaration - Signatures are to be sought when a patient refuses treatment/transport, unless a patient refuses to sign or a Paramedic is placed at risk. If the patient refuses to sign, record this in the “Observations/Drug and Fluid Treatments” section. Paramedics should always complete and leave the Patient Advice Card with the patient/carer regardless of which section is signed i.e. “Non Transport Declaration” on the PHCR or “Non Transport Declaration” detachable portion on the Patient Advice Card and complete the “Pt. Advice Card” field. If the “Non Transport Declaration” detachable portion of the Patient Advice Card is signed, this must be stuck to the bottom right hand corner of the “Observations/Drug and Fluid Treatments” section. Protocol (P2) must be written in the “Protocol” section.



10. SOP for PTO PHCR Completion

10.1 General Information

For detailed information on correct method of completing the PHCR refer to Section 9.1 of the SOP.

10.2 PTO PHCR Information

PTP PHCR Field Always Mandatory Mandatory when dictated by the circumstance

Responses

PHCR Number b Printed identification number on form

Incident Number b 5-digit number Date (DD/MM/YY) b i.e. 070605 Patient of b i.e. Patient 1 of 1

Patient 2 of 3 Car Number b Responding car number Assist Car Number b if more than one car

in attendance Other assisting car number

Previous Transports b Y – Yes N – No U – Unknown

For further information refer to Section 9.2 of the SOP

Patient of – usually this will be Patient 1 of 1. If one incident number is issued by CAD for a case requiring transport of multiple patients (3 patients for example) then record 1 of 3; 2 of 3; and 3 of 3 accordingly on each PHCR. If an incident number is issued for each patient on a multi-patient transport 1 of 1 should be completed on each PHCR/PTO PHCR.



10.3 PTO Patient Information

PTO PHCR Field Always Mandatory Mandatory when dictated by the circumstance

Responses

Title b MR , MRS, MIS, MS, REV, SR, EST, BAB, MAS, DR

Patient Names (Family, Middle and Given)


available

Name

Patient Address, (Town, Suburb and State)


available

Name

Gender b F – Female M – Male U - Unknown

Date of Birth (DDMMYYYY)

b i.e. 01011944

Age b Age in whole years for older than 2 years and

whole months for younger than 2 years

Age

Interpreter Needed b if required complete if applicable in all circumstances

Language Spoken b if interpreter required

Indicate Language

Aboriginal or Torres Straight Islander

b when patient identifies as such


For further information refer to Section 9.3 of the SOP.



10.4 PTO Transport Information


Responses

Patient Location (From) and Hospital Code

b Location address

Destination Address (To) and Hospital Code

b If no transport occurs,

leave blank

Destination address


10.5 PTO Disposition


Responses

Disposition b One and only one of the options MUST be

selected

Select one Disposition: - Transported - Transport Declined - Unable to Locate Patient - Assist Treat/Load - Transport Retrieval Teams - Operational Standby - Sporting/Special Event

(excludes major incidents and s44)

Transport Declined – complete this field when patient declines/refuses transport, Paramedics should record the circumstances of the incident in the “Reason for Transport” section. This should be an extremely rare occurrence for Patient Transport Officers. For further information refer to Section 9.5 of the SOP.



10.6 PTO Exempt


Responses

Exempt b whenever one of the exemption occurs

Select one Exempt: - Corrective Services - Police Custody


10.7 PTO Sub Category



Sub Category b Overseas Tourist For further information refer to Section 9.7 of the SOP.

10.8 PTO Journey



Journey b Single Return

Multistage b 1st 2nd Final




10.9 PTO Escort



Escort b Complete if any escort travels in the vehicle with a patient for the purpose of the patient’s care/service.

Police Nurse MO (Medical Officer)

If a nurse or medical officer is the key provider of clinical care to the patient they should complete their own clinical notes/record. Paramedics must still complete a PTO PHCR and record this in the Patient History section.


10.10 PTO MRN/Medicare/Pension/Concession Number



MRN/Authority b Enter the patient’s Medical Record Number or the Medical Officer’s name who is authorising the transfer

Number or Name

Medicare Number b If not available, leave

BLANK

10 Digits e.g. 1234 56789 0

Pension/Concession Number

b If not available, leave

BLANK

Aged Pension • 9 numbers + 1 alpha

DVA Pension • use the “Service

Number” in the bottom right hand corner of the card.

DVA b Complete if pension number is DVA.


For further information refer to Section 9.10 of the SOP



10.11 PTO Main Condition/Prob.


Responses

Main Condition/Problem

b ONE field MUST BE COMPLETED

Main Condition/Problem – select the condition/problem that best describes the circumstances of the patient.

10.12 PTO Times

PTO PHCR Field Always Mandatory


Responses

Booked b Time Scene b Time Patient Contact b Time Depart Scene b Time Triage b Time Off Stretcher b Time Odometer Beginning b Odometer End b

Include all six digits including leading zeros.

Pat.Sport Release b release time for patients trapped; or time released from sporting standby

Time




10.13 PTO Reason for Transport and Observations



Responses

Reason for Transport b Record reason(s)

Time Time

Pulse Rate per minute

Respiratory Rate

b Complete i.e. if patient deteriorates

Rate per minute

Reason for Transport - give a brief summary of the reason for the transport. It is also suggested that any other pertinent information be included in this section, for example, difficulties encountered with transfer, delay, or extra equipment/effects requiring transfer with patient.

Observations – record if indicated i.e. if patient condition deteriorates.



10.14 PTO Current Medications, Aggressive Patient/Incident, Interventions Required, O2 Therapy, Research



Responses

Current Medications b Patient on Meds. Yes, No, Unknown Meds. with Pt. on scene Yes, No. Meds. Transport with Pt. Yes, No

Aggressive Patient b whenever a real or potential hazard /aggressive patient /situation exists

complete if applicable in all circumstances: Scene; and/or Final

Aggressive Patient Comments

b whenever a real or potential hazard /aggressive patient /situation exists

Brief explanation of situation/hazard

Interventions Required

b whenever a patient’s condition deteriorates

complete if applicable in all circumstances – A PHCR must be completed if treatment provided other than oxygen administration

Oxygen Therapy b whenever oxygen is administered

High or Low

Research b when advised by instructional circular

As advised



Current Medications – is to be completed as per information provided by the patient/relative/other. If there is no information provided by the patient/relative/other, complete “Unknown” field.

Aggressive Patient/Incident - PTOs identifying aggressive patients/situations must also complete additional forms, (refer to Instructional Circular ICO1/12).

Interventions Required – in cases where a patient’s condition deteriorates and intervention is required, a PHCR must be completed, outlining further details of the patient’s condition and any treatment administered by PTOs.

Oxygen Therapy – PTOs are to administer oxygen according to their level of training and/or at the request of an attending medical officer/nurse.

Nebuliser – PTOs are not authorised to administer drugs.

Nasal Prongs – these are not supplied nor approved for use by PTOs. These are to be utilised only when supplied and requested by attending medical officers/nurses of the transferring facility.

10.15 PTO Signatures


Responses

Driving Officer Name / Signature / Employee Number / Level

b Name Signature Employee Number

Treating Officer Name / Signature / Employee Number / Level

b Name Signature Employee Number

Third Officer/Escort/Other Name / Signature / Employee Number / Level

b Including escorts and other treating officers, such as Nurses, First Responders, and Honorary Paramedics.

Report Checked Station Officer / Delegate Name / Station Name / Signature / Employee Number / Level

b Print name Print Station NAME, not Station Number Signature Employee Number Training level

For further information, refer to Section 9.33 of the SOP.



11. SOP for ECP form Completion

ECP – Referral/ Further Clinical Notes Additional form to be used in conjunction with PHCR July 2009

Specific Objectives Clinical It is the responsibility of the Trained ECP Officer to complete records pertaining to patient care. The overall patient information becomes an integral part of the data being collected outlining patient assessment and treatment by ECPs.



Summary of Modification / addition to the current PHCR form (July 09) PHCR Section Description Reason for inclusion 9.33 ECP Field on PHCR

Complete this field if a PHCR ECP form is completed and attached.

To ensure linkage of all patient records where PHCR ECP forms are used.

ECP Additional Form completion

The additional form is specific to ECP trained paramedics providing a letter of referral to the local GP, Health Assessment Teams or Community Health facilities. The form will also facilitate additional clinical notes.

To ensure linkage of all patient records where PHCR ECP forms are used. The data from the current referral letters and additional clinical notes is not submitted or collected.



11.1 ECP General Information Standing Operating Policy For Completion of the additional form in conjunction with the current version PHCR version 4.0 – for use by trained ECP officers 11.2 ECP Form Information

ECP Form Field Mandatory Responses Comments PHCR number yes Alpha-numeric Enter identifier from

original PHCR Incident number yes 5-digit number Date (DD/MM/YY) yes i.e. 011298 Car number yes Responding car

number

DRG N/A N/A Field not yet in use 11.3 ECP Patient Information

ECP Form Field Mandatory Responses Title yes MR, MRS, MIS, MS, REV, SR, EST, BAB,

MAS, DR Patients names (Family, Middle and Given)

yes Name

Gender Yes F- female M- male

Date of birth yes i.e. 01011980 Age yes - Age in whole

years for >than 2 yrs and whole months for <than 2 yrs

Age of patient

All the patient information must be recorded same as on the original PHCR form.



11.4 ECP Impression

ECP Form Field Mandatory Responses Impression As applicable to

patient assessment Free text of considered provisional diagnosis

11.5 ECP Urine analysis

ECP Form Field Mandatory Responses Urine analysis As applicable to

patient assessment Enter as DASH in fields characterised by Positive or Negative circles.

11.6 ECP Wound Care

ECP Form Field Mandatory Responses Wound Care As applicable to

patient assessment and treatment

Enter as DASH in fields characterised by circles. Enter alphabetic or numerical characters in fields characterised by boxes.



11.7 ECP Procedures

ECP Form Field Mandatory Responses Comments ECP Procedures As applicable to patient

assessment / treatment Enter a dash in fields characterised by circles, Enter alphabetic or numerical characters in fields characterised by boxes.

Results as noted following various assessments.



11.8 ECP Referral letter / further clinical notes

ECP Form Field Mandatory Responses Comments Referral letter /further clinical notes

Applicable when referring patient for further treatment. Additional free text space for further clinical notes

Written in free text. Copy of additional form to be submitted with the PHCR



11.9 ECP Signatures / employee number

ECP Form Field Mandatory Responses Comments ECP Yes Print name

Signature Employee number

Verifying your attendance to the case.

Report checked S/O Delegate

Yes Print name Signature Employee number

To be checked by the ECP delegate/ clinical support



12. SOP for ART PHCR Completion For detailed information on correct method of completing the ART PHCR refer to Section 9.1 of the SOP. Mandatory data fields for ART PHCR are listed below:

• All ART cases must complete the Incident no/Date on PHCR. This information must be the same as their original PHCR.

• All ART cases must complete the Patient Information such as Names, DOB and Address on PHCR. This information must be the same as their original PHCR.

• All ART cases must complete the “Assist Car Number” on PHCR – it is the car that the ART crew takes over from (i.e. the car that originally picked up the patient.)

• All ART cases should stipulate the hospital at which they worked. (To be completed in the PHCR “Patient Location” section.)

• All ART cases must have disposition completed as “Assist Treat /Load”, nothing else.

• All ART cases must have the ‘single’ journey box marked.

• The patient contact times (scene, Patient Contact, Off Stretcher) are the time that you (the ART crew) actually took over the patient.

• All ART cases must indicate the word “ART” on PHCR “Patient/Incident” area.



13. References

Ambulance Service NSW, “Drug Management Policy”, Ambulance Service NSW SOP—2008-014.

Ambulance Service of NSW, (2009) “Protocols and Pharmacology”, Ambulance Service of NSW, Rozelle, Sydney, Australia. Also available at: http://intranet/

Ambulance Service of NSW, (1999) “State Standard Operating Procedures and Policies Manual’, Ambulance Service of NSW, Rozelle, Sydney, Australia. Available at: http://intranet/

NSW Health Privacy Manual – Version 2 available at http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_593.pdf

NSW Health, (June-2002) “Health Publications – Patient Matters Manual”, NSW Health Department. Available at: http://www.health.nsw.gov.au/pubs/a-z/p.html

14. Appendix 1 – Summary of Health Privacy Principles

COLLECTION PRINCIPLES Privacy Manual Section 7

HPP 1 Purposes of collection of personal health information

Personal health information must be collected by lawful means and for a lawful purpose. The purpose must be directly related to, and reasonably necessary for, an organisation’s functions or activities.

HPP 2 Collection and Information sought to be relevant, not excessive, accurate and not intrusive

HPP 3 Collection from individual concerned

Personal health information must be collected from the individual it relates to, unless that is unreasonable or impractical.

HPP 4 Individual to be made aware of certain matters

Reasonable steps must be taken to inform the individual about how the information may be used, who may access it, and the consequences of not providing it.

The individual should be told what agency is collecting the information and that they have a right to access it.

This information should generally also be given to the individual where information about them is collected from someone else, unless certain exemptions, listed in the Act and the Statutory Guidelines apply.

SECURITY PRINCIPLES Privacy Manual Section 9

HPP 5 Retention and security

Personal health information held by public health agencies must be securely housed and protected against loss or misuse.

Information must be kept only as long as is necessary for the purpose (or as required by a law, such as the State Records Act), and must be disposed of securely.

ACCESS AND AMENDMENT PRINCIPLES Privacy Manual Section 12

HPP 6 Information about personal health information held by organisations

Organisations that hold personal health information must allow individuals to find out whether they hold information about that individual, and, if so, what kind of information they hold, what it is used for, and whether and how the individual can access it.

HPP 7 Access to personal health information

Individuals must be allowed to access the personal health information an organisation holds about them. This must be done without excessive delay or expense.

HPP 8 Amendment of personal health information



COLLECTION PRINCIPLES Privacy Manual Section 7

Individuals may request that their personal health information be amended to ensure that it is accurate, relevant, up to date, complete and not misleading.

Organisations must either make the requested amendments or, if requested, attach to the information a statement by the individual of the amendment they sought.

ACCURACY PRINCIPLES Privacy Manual Section 10

HPP 9 Accuracy

Organisations must take reasonable steps to ensure that the personal health information they hold is relevant, up to date, complete and not misleading.

USE PRINCIPLES Privacy Manual Section 11

HPP 10 Limits on use of personal health information

Personal health information can be used for the purpose for which it was collected or a directly related purpose.

Information may be used for other purposes only in circumstances defined in legislation. This includes where the person has consented to the use, there is a lawful excuse or the use is a “directly related purpose” such as management, training, research, investigation, law enforcement and serious threats to individuals or the public.

DISCLOSURE PRINCIPLES Privacy Manual Section 11

HPP 11 Limits on disclosure of personal health information

The provisions for disclosure of personal health information are the same as those for use of this information.

They also include a provision that a person’s personal health information may be disclosed to immediate family members for compassionate reasons, provided that this is not contrary to the expressed wish of the individual.

OTHER PRINCIPLES Privacy Manual Sections 8 & 13

HPP 12 Identifiers

Identifiers can only be applied to personal health information if this is reasonably necessary to carry out the organisation’s functions.

Public health system identifiers may be used by private sector agencies, but only in defined circumstances and with strict controls.

HPP 13 Anonymity

Provided that it is lawful and practicable, individuals should be given the option of not identifying themselves when dealing with health organisations.

HPP14 Transborder data flows and data flows to Commonwealth agencies

As a general principle, personal health information must not be transferred to a Commonwealth agency or an organisation in another state jurisdiction unless the receiving agency applies personal health information privacy policies and procedures substantially similar to those of NSW.

HPP 15 Linkage of health records

Personal health information must not be included in a system that links health records of one health service with health records in another health service unless the individual it relates to has expressly consented.

The full text of the Health Privacy Principles (or HPPs) is set out in Schedule 1 of the Health Records and Information Privacy Act 2002, available at: http://www.legislation.nsw.gov.au/maintop/scanact/inforce/NONE/0 For further guidance on the HPPs, refer to the NSW Health Privacy Manual. Relevant section references are provided. The Privacy Manual is available on the NSW Health Intranet at: http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_593.pdf



15. Glossary of Terms ID TERM EXPLANATION

A Abor./TSI Aboriginal or Torres Straight Islander

Absent Not there

Adult In legal terms this is a person 18 years old or more

Age (Y) Age in years

Aggressive Pat./Inc. A patient that is verbally or physically aggressive or an incident that is threatening

Air Bag Activated Vehicle Safety Air Bag Activation following a vehicular incident

AMT Abbreviated Mental Test

Approx. Ext. mls Approximate external blood loss in millilitres

Art. Tourniquet Arterial Tourniquet

Service Ambulance Service of New South Wales

AVPU Patient response is Alert; Responds to Verbal stimulation; Responds to Painful stimulation; Unresponsive

B Backing Sheet Another name for the Codes Sheet

Blood Glucose Level (B.G.L). Blood Glucose Level

Breath Sounds L R Lung sounds heard through a stethoscope on L = Left and R = Right sides

Bypass Situation where an ambulance must bypass a local hospital either due to Trauma Triage; Ambulance Code Red; or Medical Reason, Mental Health

C CAD Computer Aided Dispatch

Cancelled Incidents where services are no longer required

Cardiac Management Data collected pertaining to Cardiac Arrest and Cardiac treatment

CARE Clinical Assessment and Referral Program (previously known as EDM – Expended Decision Making)

Casualty Station An ambulance station that has been specifically designated as a location where a patient can be treated and may not need to be transported to hospital.

Chest Thrusts Manual pressure applied to the lower chest wall to assist expiration such as that needed for an asthmatic

Chief Complaint Main injury/illness or problem that the patient complains about

Chief Protocol Main protocol followed according to the patient's main complaint/problem/signs/symptoms

Clear (Airway) An airway that is not obstructed

Clinical Risk Advice Line A help desk for clinical risk advice 042 823 8423/0428ADVICE

Clinical Documentation Any form completion or notes recorded regarding medical conditions/problems/illnesses/injuries/treatment/tests/ observations/drug administration

Clinically Significant Any information that is crucial to the medical treatment

Codes Sheet A sheet containing codes for various sections on the PHCR/PTO PHCR. Also known as Backing Sheet.

Consent The giving of permission by a person

CPR Cardio Pulmonary Resuscitation

CPR Prior to Arrival Any CPR performed before arrival whether administered by Paramedics or others

D Dash A horizontal pen stroke

Data field An item on the health records with a circle or square next to it

DC Shock An electric shock administered from a Defibrillation machine measured in Joules

Defib. The administration of an electric shock from a Defibrillation machine



ID TERM EXPLANATION

Diagram The diagrams on the PHCR that enable a visual description of injury/illness/pain/motor vehicle crash etc

Diastolic The resting phase of the heart rhythm

Dispatch Refers to the process of allocating a vehicle to an incident by the Computer Aided Dispatch operator

Driver The person controlling a moving vehicle

DTP Decompression of a Tension Pneumothorax - A needle that is placed into the chest wall to relieve air pressure

E EAR Elderly at Risk Screen

ECG An Electrocardiograph or a measure of the electrical activity of the heart

ECG print outs The results of a measure of the electrical activity of the heart on a paper print out

ECG Rhythm The electrical rhythm or pattern of heart beat

ECG Rhythm on Arrival at Hospital

The pattern of heart beat on arrival at a hospital emergency department

ECM External Cardiac Massage

ECP Extended Care Paramedic

ED A hospital Emergency Department

Effective (Response) When there is a positive effect or an improvement of a patient's condition following the administration of a drug/pharmacology or treatment

Effort (Breathing) Usually refers to breathing and whether the type of breathing is satisfactory to sustain health or unsatisfactory requiring breathing assistance

Enroute Period during transport either to or from a destination

Est. Date of Incident/Symptom

The estimate made by asking the patient, of the time/date of incident/symptoms if this information is available and is of clinical significance

Est. Impact Speed - High Med. Low

An estimate based on the best available information that is made by Paramedics regarding possible impact speed

Est. Time of Incident/Symptom

The estimate made by asking the patient, of the time/date of incident/symptoms if this information is available and of clinical significance

Extrication The removal of a patient from a situation

F F (In various sections of PHCR)

Abbreviation for final as used on the PHCR

Final Final vitals, observations or assessments taken at end of case

Fitting/conv./post ictal A patient displaying signs of a seizure/convulsion

G Glasgow Coma Score A neurological score used to determine level of consciousness

H High Conc. Mask A particular type of oxygen mask that allows minimum oxygen to escape thus

providing more oxygen to the patient

History (Patient/Incident) A narrative of the events leading up to the incident/illness/injury and a previous history of illness/injury/incident/circumstances

Hx (Patient Incident) Medical abbreviation meaning “history”, of the illness/injury/incident /circumstances

I I.Oss An Intraosseous needle used to penetrate the bone marrow to administer drugs and fluids on neonates and infants where intravenous access is not available

IM Intramuscular injections

IN Intranasal delivery of medication

Initial The first observations - vitals, administration or treatment

Int. Intubation or placing an Endotracheal tube into a patient’s trachea

Intramuscular Inj. An intramuscular injection

IPPV Intermittent Positive Pressure Ventilation - the active process of administering oxygen via pressure

IV Intravenous or anything in the vein

L L Left hand side



ID TERM EXPLANATION

Level The level of training of the Paramedic

Level 1 Paramedic Trainee Paramedic first year

Level 2 Paramedic Paramedic Basic Life Support prior to return for in-service two training

Level 3 Paramedic Paramedic Minimum Level Basic Life Support

Level 3C Paramedic Paramedic Advanced Skills Basic Life Support

Level 4 Paramedic Paramedic Advanced Life Support

Level 5 Paramedic Paramedic Intensive Care

LMA Laryngeal Mask Airway

LMO A local medical officer/general practitioner

LOC Level of consciousness

M M & F (In Patient Information section of PHCR)

Male and Female

Manual Position The manual (hands-on) support of an airway such as chin lift and head tilt

MAST (Inflated) Medical Anti Shock Trousers are wrapped and secured with velcro around a patient's legs and/or abdomen are inflated

mcg/mg/G/mL Specific weight of a pharmacology or fluid administered

MDT Mobile Data Terminal computer installed in operational vehicles and used for Computer Aided Dispatch

Medical Facility A facility that provides medical services

Minor Something of a small nature

MISTO Information that should be recorded in the Patient/incident section of the PHCR i.e. Mechanism of Injury, Injuries, Signs and symptoms, Transport, Other.

mm Increments of measurement - millimetres

mmol/l A measure of the weight of a pharmacology in millimoles

MO Medical Officer

Mon./Defib. Machine Electrocardiograph Monitor/Defibrillation Machine

MVA/MVC/MCC Motor Vehicle Accident; Motor Vehicle Crash; and Motor Cycle Crash

MVA Single Vehicle A Motor Vehicle Accident involving only one vehicle

N Narcotic OD A drug overdose involving a narcotic drug

Ng A Nasogastric tube

Not Available (N/A) When information is not available to Paramedics

Number of Shocks Prior to your arrival

The number of electrical shocks administered to a patient prior to arrival of the officers who are completing the PHCR

O O/A On Arrival at scene

O/Defib. Other persons defibrillating the patient prior ambulance arrival

O/E On Examination of patient

O2 Therapy Oxygen Therapy

OD/Ingestions/ Poisonings

Incidents where a patient has had an overdose, ingestion, or poisoning of a substance

Ops Centre The Operations Centre - Computer Aided Dispatch occurs

Other A general/broad classification

Other Protocols Protocols other than the protocol used as a guide for the patient’s chief complaint

Other (Non-Specific) A specific Main Condition Problem is not listed on the PHCR/PTO PHCR

P PAD (Public Access Defibrillation)

Members of the general public who have been trained in the use of a heart defibrillator

Paediatric Weight (Estimate) An estimate of a neonate, baby, infant or child's weight



ID TERM EXPLANATION

Pat. Sport Release Patient/Sport Release time - The release time of either a trapped patient or the time an ambulance was released from a sporting/event standby

Patient 0 of 0 The number of patients transported on a single Incident Number

Patient Assessment Process of visually and manually checking a patient's vital signs, airway, breathing, circulation, signs, symptoms, illness, injury, potential for illness/injury

Patient Contact When an Paramedic has visual or physical contact with a person who has an injury/illness or potential to have an injury/illness

PEARL Pupils Equal And Reactive to Light

Pension DVA Department of Veteran Affairs type of Pension and Number

Pension/Concession Number Centre Link Commonwealth type pension/concession allowance

PHCR Official Patient Health Care Record of Ambulance Service NSW

POI (Point Of Impact) The point at which impact where transport vehicles are involved

Present In existence

Primary Survey A physical examination consisting of a systematic and thorough inspection of potentially life-threatening areas (i.e. Airway, Breathing, Circulation, Disability and Exposure)

PTO A Patient Transport Officer of the Patient Transport Service of the Ambulance Service of NSW

PTO PHCR The Patient Transport Officer Patient Health Care Record

PTO PHCR Copies The copies of the original PHCR or PTO PHCR such as the Medical Review Copy and the Hospital Copy

P1 Paramedic/ALS/Paramedic with P1 Training

R R Right hand side

Resp. Rate Respiratory rate or the number of breaths at which a person is breathing per minute

Retrieval Transport of a medical team and/or equipment with or without patient

Route The way in which a drug or fluid is administered such as intravenously, intramuscularly, sublingually, orally or through absorption

Routine A patient transfer that is not urgent

S S "Scene" - usually an assessment "at scene"

SA/DA Sexual Assault and/or Domestic Assault

SpO2 % The saturation level of oxygen in the blood as a percentile

SCAT Special Casualty Access Team Paramedic

Scene The location of the incident or where the patient is located

Section 44 Incident A declared state of emergency – S44 of the Bush Fires Act

Sector Designated area within a broader division of the Ambulance Service of NSW

Shock (j) An electrical defibrillation shock of a particular strength measured in Joules

SO Station Officer

SOP Standard Operating Policy

Special Event An organised event such as New Years Eve celebrations

Sporting Event An organised sporting event such as annual Bathurst car races.

Stand-by When a state of readiness is required until further instructions

Stroke/CVA Injuries Stroke or Cerebro Vascular Accident

Systolic The pressure exerted on artery walls during the contraction phase of the heart beat

T Tasked When a Rescue, SCAT Officer, Helicopter or Fixed Wing Aircraft are dispatched on a case

Tension Pneumo Decomp The Decompression of a Tension Pneumothorax or release of the air pressure following a puncture to the lung by placing a needle through the chest wall

Third Officer/Escort/Other A party other than that of the normally rostered officers on duty and attending



ID TERM EXPLANATION

the case such as a Nurse, student, Doctor

Time - Art Tourn. App. The time an Arterial Tourniquet has been applied

Transport The process of transporting a patient/others to or from a hospital/medical facility

Trapped A person who is unable to be released from containment, wreckage or device

Trauma Triage Criteria used to determine trauma patient’s initial hospital destination

Treatment Assessment, first aid administration, advanced life support administration, pharmacology and other adjuncts administration, general care of a patient

U U Unsuccessful attempts to administer or apply treatment

Unknown When information is unknown to Paramedics

Unsuccessful Unsuccessful attempts to administer or apply treatment

V Vehicle Deformity Type and extent of damage to a vehicle following an incident

Volume The space occupied by a substance

W Waiting Standing by in a state of preparedness

Weight A measurement of mass

Witness A person who saw or participated at an event

Witnessed by AO Cardiac arrest witnessed by an Paramedic

Witnessed by Public Cardiac arrest witnessed by another person other than an Paramedic

Worthing Score A physiological scoring system that provides a substantiated and quantifiable measurement of a patient’s current condition

100% Maximum possible delivery of oxygen to a patient

(M) If<2yrs Months of an age if a patient is less than 2 years of age



16. INDEX Abbreviation and symbol use .....................12 Aboriginal or Torres Straight Islander ........85 Aboriginal/Torres Strait Islander...........19, 67 Accuracy and Fact .....................................12 Adding Information .....................................14 Age.......................................................19, 85 Aggressive Pat./Inc ....................................85 Aggressive Patient .........................42, 73, 74 Aggressive Patient/Incident........................42 Airway ............................................42, 44, 85 Allergies .....................................................37 alphabetic data...........................................17 Ambulance Employees ..............................27 Ambulance Services Regulation Act 2000 .10 APVU .........................................................38 Art. Tourniquet .....................................43, 85 Assessment................................................42 Assist Car...................................................18 Assist Car Number .....................................18 Blood Loss .................................................42 Blood Sugar Level................................39, 85 Booked.................................................33, 71 Breath Sounds .....................................38, 85 Breathing....................................................42 Bypass .................................................85, 87 CAD............................................................85 Car Number..........................................18, 66 Cardiac Arrest/Management Data..............85 Category.....................................................54 Central Perfusion .......................................42 Cervical Collar............................................43 Chest Thrusts.......................................43, 85 Chief Complaint....................................35, 85 Chief Protocol.......................................48, 85 Clammy Skin ..............................................42 Clinical Documentation ..............................85 Clinical Risk Advice Line ......................53, 85 Clinically Significant ...................................85 Codes Sheet ..............................................85 Collision Patient Type ................................50 Collision Vehicle Diagram ..........................50 Collisions....................................................50 Completeness ............................................12 Contraindication .........................................54 Corrective Services ....................................26 Correctness................................................12 CPR Effective Prior to Arrival .....................47 CPR Prior to Arrival..............................47, 85 CR (Child at Risk) ......................................26 Date....................................17, 18, 19, 66, 67 Date of Incident/Symptom..........................34 Defibrillator .................................................48 Depart Scene .......................................33, 71

Destination Address (To)......................20, 68 Diastolic................................................38, 86 Dispatch .....................................................86 Dose .....................................................52, 53 Drug and Fluid Treatments...................52, 53 ECG Rhythm ........................................47, 86 Effort.....................................................38, 86 Endotracheal ..............................................44 Equipment ..................................................46 errors ..........................................................17 Escort/ ..................................................57, 74 Extrication Device.......................................46 Final stage..................................................29 first responders.....................................57, 74 GCS – Eye Opening...................................38 GCS – Motor ..............................................38 GCS – Verbal .............................................38 Gender .................................................19, 67 Glasgow Coma Score ..........................39, 86 Health Records and Information Privacy Act...................................................................11 High Concentration Mask ...........................45 History ........................................................86 Honorary Ambulance Officers ..............57, 74 Impact Speed .......................................50, 86 Incident Number ...................................18, 66 Information Privacy.....................................15 Infusion Site..........................................43, 44 Interpreter.......................................19, 20, 67 Interventions.............................43, 44, 73, 74 Intramuscular Injections .............................43 Language Spoken ................................19, 67 Legibility .....................................................12 Main Condition/Problem.......................34, 71 Manual Position....................................44, 87 Medicare Number...........................31, 32, 70 Medications ..........................................36, 73 Minors.........................................................27 Modifications ................................................6 MRN/Authority ......................................31, 70 Multistage Transport.......................26, 29, 69 MVA Single Vehicle....................................28 Nasal Airway ..............................................44 Nasal Prongs........................................45, 74 Nasogastric Tube .......................................44 Nebuliser ..............................................45, 74 Non-Re-breather ........................................45 Number of Vital Observations ....................39 numerical data............................................17 O2 Therapy ...........................................45, 87 Objectivity...................................................12 Observations ..................................52, 53, 72 Odometer Beginning ............................33, 71



Odometer End......................................33, 71 Off Stretcher.........................................33, 71 Officer Signature ........................................57 Oral Airway.................................................44 Output ........................................................47 Overseas Tourist........................................28 Oxygen Saturation ...............................38, 39 Oxygen Therapy...................................73, 74 Paediatric Weight .................................35, 87 Pain Score..................................................20 Palpable Pulse ...........................................42 Pat.Sport Release ................................33, 71 Patient of .............................18, 58, 59, 66 Patient Address....................................19, 67 Patient Assessment ...................................88 Patient Contact.....................................33, 71 Patient Family Name..................................19 Patient Given Name...................................19 Patient Health Care Record .......................11 Patient Information .....................................19 Patient Location (From)........................20, 68 Patient Middle Name..................................19 Patient Names............................................19 Patient Transport Officer ............................11 Patient Transport Officer Patient Health Care Record........................................................11 Patient/Incident History ..............................35 Pension DVA........................................32, 88 Pension Number ........................................32 Pension/Concession Number.........31, 70, 88 Pharmacology ............................................54 Pharmacology Effective .............................54 PHCR COPIES ..........................................17 PHCR Information ......................................18 PHCR Number .....................................18, 66 Poisons and Therapeutic Goods Act....11, 52 Police Custody ...........................................26 Posture.......................................................41 Posture Enroute .........................................41 Posture On Scene......................................41 Previous Transports .............................18, 66 Private Health Insurance............................27 Protocols ......................48, 60, 61, 62, 63, 64 PTO Main Condition/Problem ....................71 PTO Patient Information.............................67 PTO Reason for Transport.........................72 PTO Signatures..........................................74 PTO Times .................................................71 PTO Transport Information ........................68 PTO Treatment ..........................................73

Pulse ....................................................38, 72 Pupil Reaction ............................................39 Pupil Size ...................................................38 Reason for Transport .................................72 Refused Transport Declaration ............55, 65 Regulations ................................................10 Report Checked .........................................58 Rescue .......................................................51 Research ........................................57, 58, 73 Respiratory Rate ..................................38, 72 Retrieval .....................................................88 Rhythm.................................................52, 53 Route..............................................52, 53, 88 Scene ...................................................33, 71 Scoop .........................................................46 Shock ...................................................52, 53 Signing the record ......................................12 Site .............................................................35 Skills List ....................................................58 Skin Changes .............................................35 SOO Number..............................................51 Spine ..........................................................46 Splints.........................................................46 State Records Act ................................11, 15 Station ........................................................58 Subsequent Protocols ................................48 Suction .......................................................44 Systolic .................................................38, 88 Third Party..................................................26 Time ...............................................52, 53, 72 Time of Incident/Symptom....................34, 86 Timeliness ..................................................12 Times..........................................................33 Title.......................................................19, 67 Tme of Incident/Symptom ..........................34 Total Shocks...............................................47 Transport ....................................................89 Transport Account ................................21, 68 Transport Information .................................20 Trauma Triage............................................89 Trauma/Medical Condition .........................40 Treatment ...................................................89 Triage .........................................................33 Triage Time ................................................71 UNKNOWN ..............................19, 20, 67, 89 Vehicle Deformity .................................50, 89 Vehicle Diagram.........................................50 version........................................................17 Vitals...........................................................38 Worker’s Compensation .............................27

Documents

Patient Health Care Record SOP Version 4 - NSW · PDF filePatient Health Care Record SOP Version 4.0 ... DUTY OF CARE ... Ambulance Service of NSW Patient Health Care Records