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
9 Clone
Created by
Downs_Hayden
Related templates
Dental Health Record Template - PDF Templates

Dental Health Record Template

The Dental Health Record Template is easy for patients to fill out and designed to get the doctor the most important information. Patients can fill out their information on a computer or tablet using our Dental Health Record Template.

Healthcare
Professional Medical History Template - PDF Templates

Professional Medical History Template

Medical History Record PDF template is here to help you in order to know the patient's case and previous condition. You can collect data about the patient and medical background with this Medical History Record PDF sample.

Healthcare
Personal Medical History Template - PDF Templates

Personal Medical History Template

Medical History Record PDF template allows you to collect patients' data such as personal information, family history, and habits like, and symptoms. You can pick your patients with this medical history record sample.

Healthcare
COVID-19 Vaccine Administration Record - PDF Templates

COVID-19 Vaccine Administration Record

Keep track of patient vaccination records online. More secure with GDPR, CCPA, and optional HIPAA compliance features. Download or print as PDFs. Free, easy-to-customize template.

Healthcare
Dietary Requirements Template - PDF Templates

Dietary Requirements Template

Collect important information about food restrictions and allergies. Save submissions as PDFs. Easy to customize, download, print, and share with kitchen staff.

Healthcare
Child Medical History Template - PDF Templates

Child Medical History Template

This child medical history PDF template makes checking patients vitals and recording that important data easy. Add your own branding, adjust fields for your specific needs and then simply print out your PDF for the patient's file.

Education

These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.