EHMS v1ePCRF Template

Item - EHMS v1ePCRF Template Image-1 0
Sunday, October 6, 2024
Electronic Patient Care Record Form (ePCRF)
PRIVATE & CONFIDENTIAL
ePCRF Number:
MEDIePCR0014
Event Details:
Date & Time:
Sunday, October 6, 2024 11:15
Event Name:
RJMC
Patient Details:
Patient's Full Name:
Mason White
Date of Birth (DoB):
Thursday, November 18, 2010
Age:
13
Gender:
Male
Address:
5 Murray Ave
Redcliffs, VIC, 3496
Australia
Phone Number
(045) 710-4483
Responsible Person Details:
(parent/guardian if patient ,16 years)
Responsible Persons Full Name:
Sarah Shaw
Phone Number:
(045) 710-4483
Medical Information:
Allergies:
NKDA
Communicable Diseases:
NKCD
Past Medical History (PHx):
ADHD Anxiety
Medications (Medn):
Ritalin 100mg Melatonin
History (Hx):
13 Year old male, competing at event, was riding motorcycle when hit a tree root at speed, coming off motorbike landing on R) shoulder.
On Arrival (O/A):
Alert, Eyes Tracking, Sitting on ground with event staff, Father in attendance.
On Examination (O/E):
[CNS] GCS15, A+O PPT, PEARL+, Grip =, Push/Pull L) +, R) - (injury) *Headache, *Dizziness, *LOC, *N+V, *Seizure Activity, -ROSIER [CVS] HR (St + Reg) L & R RAD =, BP (NORMO) *Chest Pain, * Palpatations, *Tightness ; *IV Access [RESP] Full Sentences ; Quiet Breating ; Own Airway *SOB, *^WOB, *Acc Muscle Use A/E: L + R = Clear all fields [SKIN] Afebrile, Pink, Warm, Dry [2nd] *Bleeding, * Obv. Deformity, * Obv. #, Denies headstrike. Full PPE worn (helmet & chest plate). [N/VASC] Cap Refil <2, Good Sensation, Colour, Warmth. Strong Radial Pulse
Patient Observations:
Set 1:
Set 2:
Set 3:
Set 4:
Set 5:
De
le
te
d
Co
lu
mn
Time:
1110
1130
Respira
tory
Rate (
RR):
18
18
Supp 02
:
RA
RA
Sp02:
95
96
Blood
Pressu
re (BP
):
120/80
115/80
Pulse R
ate
(bpm):
112
105
Temp:
36.1
-
GCS / A
VPU:
GCS15
GCS15
Pupils
(L/R):
L+4, R+
4
L+4,R+4
Pain Sc
ore
(0-10)
:
6
4
BGL:
(mmol/
L)
-
-
Interventions / Medications:
.....
Time:111211201122--
Intervention / MedicationMethoxyfluraneParacetamolIbuprofen--
Dose:31400--
Units:MLGramMg--
RouteINHOralOral--
Any other relevant information:
On-site Medical Officer reviewed patient prior to discharge and agreed with initial assessment and recommendation . Applied sling for comfort and transport home.
Provisional Diagnosis:
AC Joint? #Collar Bone?
Recommendation / Discharge:
Recommendation / Discharge:
Sent Home / Left Event
Referral (GP, Physio, Other HCP etc.)
Discharge/Follow Up Advice:
Advised parents to continue regular analgesia and monitor patient for decreased R.O.M or Increased Pain if present, present to local ED or HCP.
Clinician Details:
Name:
H Downs
Clinical Level:
Managing Director (Ambulance Officer Adv. Prac).
Employee Number:
3043
Signature:
Item - signature 1
ePCR Reference Number:
9404
ePCRF Number:
MEDIePCR0014
Item - EHMS v1ePCRF Template Image-2 2
Responsible Person Details:
Item - EHMS v1ePCRF Template Image-3 3
Supervising Clinician Details (If Applicable) :
Location Coordinates
Longitude: 140.40449330113438 Latitude: -34.71456213141458
About this template
Categories
Details
3 Clone
Created by
Downs_Hayden
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