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A medical emergency with an individual victim.
Emergency medical record
What should an emergency medical record look like?
Last Updated: October 1, 2015
What should be displayed on an emergency medical record?
Details of the patient.
Details of the diagnosing and treating medical doctor.


Details of the patient.

Where is the patient now?

_________________________

How old is the patient?

_________________________

What is the gender of the patient?

_________________________

Who is reporting this emergency?

_________________________

What are the sources of medical history?

_________________________

Patient.
Family.
Patient not responding to medical history questions.
Community member.
Police officer.
Referral from medical doctor.
Other.

What is the reason for consultation?

_________________________

What seems to be the problem?

_________________________

How much time has elapsed from the start of the emergency until now?

_________________________

Does one individual or many individuals have medical emergencies at this location?

_________________________

How many individuals have medical emergencies at this location?

_________________________

Is it a Medical Emergency?

___________________________

Is the victim's condition life or limb threatening?

___________________________

Could the victim's condition worsen and become life or limb-threatening on the way to the hospital?

___________________________

Could moving the victim cause further injury?

___________________________

Does the victim need the skills or equipment of paramedics or emergency medical technicians?

___________________________

Would distance or traffic conditions cause a delay in getting the victim to the hospital?

___________________________

What best describes your problem?

_________________________

Patient Name:________________________

Referred by:_________________________

Mailing Address:_____________________

Telephone:___________________________

Your Email Address:__________________

Date of Birth:_______________________

Gender: Male Female

Primary Care Physician Name, Address and Phone:__________________

Emergency Contact Name:______________

Relationship:________________________

Phone:_______________________________

Your Height:_________________________

Your Weight:_________________________

Race::_______________________________

White
Black/African American
Hispanic/Latino
Pacific Islander
Asian
Asian/American

Consciousness of a human being has to be included in vital signs.

Vital Signs

Consciousness, pulse, blood pressure, respiratory rate, temperature.

Consciousness is extremely essential in reaching a correct diagnosis and treatment.

What are the vital signs on the date and time of diagnosis and treatment?

Date: Time: Consciousness: Pulse: Blood pressure: Respiratory rate: Temperature:
------- ------- ------- ------- ------- ------- -------


http://www.qureshiuniversity.com/medicalhistory.html

http://www.qureshiuniversity.com/vitals.html

Are there any obvious injuries? What are they?

Where was patient when the injuries occurred?

1. inside other building ______________________________________
2. outdoor location ___________________________________________
3. unknown Date of first E.R. Visit ____/____/____ Arrival Time :______________

How did patient get to hospital?
1. ambulance (name company____________________________)
2. private vehicle
3. public transportation
4. walked or was carried
5. helicopter
6. other (specify________________________________)
7. unknown

Was the patient transported from another health care facility?
Y/N Unknown
If yes, specify: ________________________________________

Disposition from Emergency Department
1. discharged home
2. admitted
3. transferred to other facility (specify _________________________________________)
4. left against medical advice
5. dead on arrival
6. expired in emergency department
8. other
(specify___________________________________________)
9. unknown

If patient was admitted:
Date of Admission ____/____/____ Date of Discharge/Death ____/____/____

Discharge Disposition:
1. home
2. acute care hospital _____________________________
3. skilled nursing facility __________________________
4. intermediate care facility ________________________
5. other hospital ___________________________________
6. home health care
7. left against medical advice
8. expired in hospital
9. other _________________________________________
10. unknown

How did injury occur:
Injury Report Form
Are long-term physical disability/sequelae likely?
___definite
___likely
___unlikely
___unknown
If so, what type of disability?
___neurologic
___physical
___hearing
___vision
___ other

Details of the diagnosing and treating medical doctor.

What is the name, date of birth, phone number, and other contact information of the person diagnosing and treating this patient?

_____________________________________________

What is the date and time you are diagnosing and treating this patient?

_____________________________________________

What is the location of the patient at the time you are diagnosing and treating this patient?

_____________________________________________

What best describes the location of diagnosis and treatment of this case?
1. On-the-spot diagnosis and treatment.
2. Emergency room diagnosis and treatment.
3. In the hospital diagnosis and treatment.
4. Long-distance health care advice.
5. Other
_____________________________________________
Can you reach a correct diagnosis and treatment of a human being?

_____________________________________________

What is the diagnosis of this patient?

_____________________________________________

How did your reach this diagnosis?

_____________________________________________

What is the treatment for this patient?

_____________________________________________

Does the patient need to be transferred to a medical emergency room?

_____________________________________________

In America up to February 12, 2012, most emergency medical records did not have these facts.

In what emergency medical category do you fit the condition of the patient you are diagnosing and treating on this date and time?

Undetermined, Good, Fair, Serious, Critical.

If on-the-spot diagnosis of a patient declared in serious or critical condition, arrange a bed in the Intensive Care unit.

How are most patients categorized in American triage locations up to February 12, 2012?

Immediately life threatening
Urgent, but not immediately life threatening
Less urgent

How should patients be categorized around the world, including in America, in case of a medical emergency?
Undetermined, Good, Fair, Serious, Critical.

Fair, serious, or critical will always get a medical diagnosis that needs emergency treatment.

This can be only done by an emergency medical doctor able to reach the correct diagnosis and provide treatment.

Is there a difference between emergency and non-emergency medical diagnosis?
Yes, there is.

What is the difference between non-emergency and emergency medical diagnosis?
This example will make you understand.
Diabetes is a non-emergency medical diagnosis.
Diabetes with hyperosmolar coma or diabetic ketoacidosis is an emergency medical diagnosis.

Date of Examination:_________________________

Physician Name:_________________________

Physician Address:_________________________
Annual health assessment.
Here are further guidelines.
Surgical history.

Have you ever undergone surgery?
(Yes / No)
If yes, please list operations and dates:

Social history

Do you smoke now?
(Yes / No)
How much?
__________________

Have you ever smoked?
(Yes / No)
If yes, for how many years?
________
When did you quit?
_______________

Do you drink alcohol?
(Yes / No)
If yes, how much?
__________________
How often?
___________________

Have you used recreational drugs?
(Yes / No)
If yes, which ones?
_______________________________________________

When was the last time you used one/them?
___________________________

Allergies

Are you allergic to anything (medications, foods, latex)?
(Yes / No)
If yes, please list:

Do you need assistance with getting around( ie cane, wheel chair, etc)?
(Yes / No)

Do you exercise?
(Yes / No)

(For women only)
Are you pregnant or breast feeding? _____________________
Date of your last menstrual period: ______________________
How many children do you have? ______________________
How were they delivered? ______________________

Human Vital Signs

1. Consciousness:_________________________

2. Pulse rate:_________________________

3. Blood pressure:_________________________

4. Respiration rate:_________________________

5. Body temperature:_________________________

6. Emotion:_________________________

Vital Signs. These are some vital signs checked by your doctor:
Blood pressure: less than 120 over 80 is a normal blood pressure. Doctors define high blood pressure (hypertension) as 140 over 90 or higher.
Heart rate: Values between 60 and 100 are considered normal. Many healthy people have heart rates slower than 60, however.
Respiration rate: Around 16 is normal. Breathing more than 20 times per minute can suggest heart or lung problems.
Temperature: 98.6 degrees Fahrenheit is the average, but healthy people can have resting temperatures slightly higher or lower.

Vision & Hearing Screening

Height:_________________________

Weight:_________________________

Waist, hip circumferences:_________________________

BMI:_________________________

    Calculate the body mass index (BMI = wt (kg) รท ht(m2)
    < 20 BMI Low body weight
    20 to 25 BMI Healthy weight for most people
    >25 to 27 BMI Weight may lead to health problems
    27 to 29 BMI Overweight. Associated with increase in morbidity and mortality.
    > 30 BMI Obese
Eyes:_________________________

Ears/Nose:_________________________

Oral Cavity:_________________________

Endocrine:_________________________

Lymph Nodes:_________________________

Lungs:_________________________

Heart:_________________________

Breasts:_________________________

Abdomen:_________________________

Genitals:_________________________

Female Physical Exam:_________________________

Male Physical Exam:_________________________

Extremities / Musculoskeletal:_________________________

Habitus:_________________________

Skin:_________________________

Psychiatric:_________________________

Neurologic:_________________________

Laboratory Tests

Complete blood count

Chemistry panel

Urinalysis (UA)

Prescription

Here are further guidelines.