NSW Ambulance eMR data request form - Home - · Web viewNSW Ambulance eMR Data Request Form ii...

NSW Ambulance electronic Medical Record (eMR version 2.3.1)Data Request Form

October 2015

Dear Researcher

NSW Ambulance datasets

NSW Ambulance routinely collects operational and clinical data. Operational data are captured in the Computer Aided Dispatch (CAD) system. The paper-based Patient Health Care Record (PHCR) and electronic Medical Record (eMR) are NSW Ambulance’s principal clinical datasets.

This document lists the research-related variables captured in eMR that may be requested for research purposes. Brief descriptions and possible predefined values of these data elements are provided.

Operational information

o CAD is a centralised state-wide emergency and patient transport call-taking and dispatch system that utilises VisiCAD software for the logging and allocation of resources to Triple Zero (000) calls.

o It has an integrated mapping component that displays vehicle and incident information in real time and utilises GPS tracking of all frontline ambulances to assist in the dispatch process.

o CAD records are available from July 2000.

Clinical information

o Data collected during the patient care episode are recorded by paramedics in either the PHCR or eMR. This includes information about the incident (e.g. reason for call and scene location), patient information (e.g. demographics, injury/illness characterisation, vital signs and assessment results), treatment details (e.g. pharmacology and interventions), and outcomes (e.g. transported, not transported, died).

o Paramedics complete a clinical record for all incidents including inter-hospital/facility transfers. Clinical records are required, even if there is no patient contact, for all road traffic incidents, for incidents where the patient cannot be found or has left the scene, or where services are not required. Cases where a patient is already deceased prior to paramedics’ arrival are also documented.

o Since its staged introduction in 2011, the eMR is the preferred clinical record.

o The PHCR is completed by paramedics only in the absence of an eMR. At the time of writing, Extended Care Paramedics, volunteers and single responders only use the PHCR. The PHCR is also used in some regional areas.

o Unlike the PHCR, the eMR directs compulsory completion of some screens/fields.

o PHCR data are available from April 2001 and eMR data are available from 2011.

NSW Ambulance eMR Data Request Form i

This document lists research-related fields recorded in the eMR.

Please enter your research question/s and the relevant date range/s in the table below. On subsequent pages, indicate the variables required to:

Identify cases of interest (inclusion/exclusion criteria) - e.g. determining included cases by ‘case nature’. Address the research question.

Please also briefly outline how each variable directly relates to the stated research question/s.

CAD and PHCR data requests should be lodged separately if required.

Please note that data extraction is associated with a cost to NSW Ambulance. These costs may be passed on to the researcher. Costs are determined by the extent of work that is necessary to satisfy the request.

Data will not be provided for non-specific enquiry.

Please direct queries to:

E: [email protected]

P: 02 9779 3865

NSW Ambulance eMR Data Request Form ii

Date range/s of interestClick here to enter text.Research question/s

1 Click here to enter text.Click here to enter text.



mailto:[email protected]

Description Required? Justification for this requestCrewFleet unit # Vehicle number and division ☐ Click here to enter text.Unit skill set The highest clinical level of the crew ☐ Click here to enter text.CaseCase number (EPCIRD) Unique eMR incident number ☐ Click here to enter text.Date Date of incident ☐ Click here to enter text.Case given as Suspected patient problem, e.g. ‘fall’ ☐ Click here to enter text.Odom start (km) ☐ Click here to enter text.Dispatch code Priority – e.g. ‘lights & sirens’ emergency or urgent ☐ Click here to enter text.SceneLocation type E.g. residence, hospital ☐ Click here to enter text.Common location List of high frequency locations specific to an area ☐ Click here to enter text.Location name E.g. Residential Aged Care Facilities ☐ Click here to enter text.Street Full street information ☐ Click here to enter text.Suburb Suburb - postcode auto pop ☐ Click here to enter text.State E.g., NSW, Victoria ☐ Click here to enter text.

NSW Ambulance eMR Data Request Form 1

In all Tables, yellow shading denotes data fields that are

Description Required? Justification for this requestPatientGender The patient’s sex: male/female ☐ Click here to enter text.

Date of birth Full date of birth will only be supplied if sufficient justification is supplied that age is insufficient. ☐ Click here to enter text.

Age Best estimate or actual ☐ Click here to enter text.Address (patient)As scene May be same as scene address ☐ Click here to enter text.Location name Landmarks only, including Residential Aged Care Facilities ☐ Click here to enter text.Street The patient’s street name ☐ Click here to enter text.Suburb The patient’s suburb ☐ Click here to enter text.State The state in which the scene is located, e.g., NSW, Victoria ☐ Click here to enter text.


Past historyPre-existing conditions Select from REFERENCE TABLE 1, pages 4 and 5Required? Click here to enter text.Justification for this request: Click here to enter text.AllergiesJustification for this request: Click here to enter text.

Click here to enter text.Indicate required fields: No Known Allergies ☐ Local Anaesthetic ☐

Unknown Allergies ☐ Mannitol ☐Adhesive Tape / Dressing ☐ Metaraminol Bitartrate ☐Adrenaline Tartrate ☐ Methoxyflurane ☐Amiodarone ☐ Metoclopramide ☐Antibiotic ☐ Midazolam ☐Aspirin ☐ Milk Products ☐Atracurium ☐ Morphine Sulphate ☐Atropine Sulphate ☐ Naloxone Hydrochloride ☐Bee / Wasp / Ant Sting ☐ Nifedipine ☐Benztropine ☐ NSAIDs ☐Birds / Feathers ☐ Nuts / Seeds ☐Box Jellyfish Antivenom ☐ Ondansetron ☐Chlorhexidine ☐ Other ☐Chocolate ☐ Pancuronium Bromide ☐Codeine or Prescribed Opiates ☐ Paracetamol ☐Dextrose ☐ Parecoxib Sodium ☐Diazepam ☐ Pet Hair ☐Dobutamine ☐ Pethidine Hydrochloride ☐Dopamine ☐ Prochlorperazine ☐Drixine ☐ Promethazine ☐Eggs ☐ Propofol ☐Entonox ☐ Rocuronium ☐Fentanyl ☐ Salbutamol ☐Fruit / Vegetable ☐ Seafood ☐Frusemide ☐ Sodium Bicarbonate ☐Glucagon ☐ Steroid ☐Gluten ☐ Suxamethonium Chloride ☐Glyceryl Trinitrate ☐ Tirofiban ☐Grass / Pollen ☐ Tramadol ☐Haloperidol ☐ Vaccine ☐Hartmanns ☐ Vecuronium ☐Heparin ☐ Verapamil Hydrochloride ☐Iodine / Betadine ☐ Vinegar ☐Ipratropium Bromide ☐ Virkon ☐Latex ☐ Wheat ☐Lignocaine Hydrochloride ☐ X-Ray Contrast ☐

Zinc ☐


REFERENCE TABLE 1: Pre-existing conditions (continued on page 5)Nil Known ☐ Atrial Fibrillation ☐ Cardiomyopathy ☐ Deep Vein Thrombosis ☐ Gallstones ☐Unknown ☐ Atrial Flutter ☐ Carotid Endarterectomy ☐ Dementia ☐ Gastric Reflux ☐Abdominal Aortic Aneurysm ☐ Autonomic Dysreflexia ☐ Carotid Stenosis ☐ Depression ☐ Glaucoma ☐Abdominal Aortic Aneurysm ☐ Repair ☐ Back Pain ☐ Cataract/s ☐ Diabetes ☐ Gout ☐Abdominal Pain ☐ Back Problems ☐ Cataract Surgery ☐ Dialysis ☐ Grommets ☐Acquired Brain Injury ☐ Back Surgery ☐ Cellulitis ☐ Diarrhoea ☐ Haematemesis ☐Acute Myocardial Infarction ☐ Bipolar Disorder ☐ Cerebral Aneurysm ☐ Dislocation ☐ Haematuria ☐Angiogram ☐ Bladder Cancer ☐ Cerebral Haemorrhage ☐ Diverticular Disease ☐ Haemoptysis ☐Acute Pulmonary Oedema ☐ Bleeding Disorder ☐ Cerebral Palsy ☐ Down's Syndrome ☐ Haemorrhoids ☐AIDS ☐ Bleeding in Pregnancy ☐ Chest Infection ☐ Drug Abuse ☐ Hallucinations ☐Alcohol Abuse ☐ Bleeding - Other /Not Listed ☐ Chest Pain ☐ Drug Overdose ☐ Headache ☐Alcohol Overdose ☐ Bone Cancer ☐ Cholecystectomy ☐ Ear Infection ☐ Hearing Loss ☐Alzheimer's Disease ☐ Bowel Cancer ☐ Chronic Obstructive Pulmonary

Disease ☐ Eating Disorder ☐ Heart Transplant ☐Amputation ☐ Bowel Obstruction ☐ Cirrhosis ☐ Ectopic Pregnancy ☐ Heart Valve Problem ☐Anaemia ☐ Bowel Resection ☐ Coeliac Disease ☐ Emphysema ☐ Heart Valve Repair ☐Anaphylaxis ☐ Bradycardia ☐ Colostomy / Ileostomy ☐ Encephalitis ☐ Hemiparesis ☐Angina ☐ Brain Surgery ☐ Congenital Heart Defect ☐ Endometriosis ☐ Hemiplegia ☐Angioedema ☐ Brain Tumour / Cancer ☐ Constipation ☐ ENT Problem ☐ Hernia ☐Anxiety ☐ Breast Cancer ☐ Corneal Transplant Epiglottitis ☐ Hepatitis A ☐Appendicectomy ☐ Bronchiolitis ☐ Coronary Artery Graft Surgery ☐ Epistaxis ☐ Hepatitis B ☐Arm Pain ☐ Bronchitis ☐ Coronary Angioplasty/ Stent ☐ Eye Injury / Problem ☐ Hepatitis C ☐Arrhythmia-Other/Not Listed ☐ Bundle Branch Block ☐ Cough ☐ Fainting Episodes ☐ Hip Joint Replacement/ Repair ☐Arthritis – Osteo ☐ Burn/s ☐ Cramps ☐ Falls ☐ HIV Positive ☐Arthritis – Rheumatoid ☐ Cancer - Other / Not Listed ☐ Crohn's Disease ☐ Femoropopliteal Bypass ☐ Hydrocephalus ☐Ascites ☐ Cardiac Arrest ☐ Croup ☐ Fracture - Neck of Femur ☐Asthma ☐ Cardiac Failure ☐ Cystic Fibrosis ☐ Fracture - Other ☐


REFERENCE TABLE 1 continued: Pre-existing conditionsHypercholesterolaemia ☐ Lung Surgery Pancreatic Cancer ☐ Renal Calculi / Colic ☐ Throat Infection ☐Hyperlipidaemia ☐ Lung Transplant ☐ Pancreatitis ☐ Renal Failure ☐ Thrombolysis (Cardiac) ☐Hypertension ☐ Lymphoedema ☐ Panic Attack ☐ Respiratory Arrest ☐ Thrombolysis (Cerebral) ☐Hyperthyroidism ☐ Malignant Hyperthermia ☐ Paraplegia ☐ Respiratory Tract Infection ☐ Thrombolysis (Other) ☐Hypotension ☐ Melaena ☐ Parkinson's Disease ☐ Rhinoplasty ☐ Thyroid Surgery ☐Hypothyroidism ☐ Meningitis ☐ Peg Tube ☐ Schizophrenia ☐ Tonsillectomy ☐Hysterectomy ☐ Menstrual Disorder ☐ Pericarditis ☐ Seizure/s / Convulsion/s ☐ Tracheostomy ☐Incontinence - Faecal ☐ Migraine/s ☐ Peripheral Vascular Dis. ☐ Self Harm Attempt ☐ Transient Ischaemic Attack ☐Incontinence - Urinary ☐ Motor Neurone Disease ☐ Personality Disorder ☐ Self Harm Thoughts ☐ Tremor ☐Infectious Disease - Other / Not Listed ☐ Multiple Sclerosis ☐ Plastic Surgery ☐ Sepsis ☐ TURP ☐Influenza Illness ☐ Myasthenia Gravis ☐ Pleural Effusion ☐ Septicaemia ☐ Ulcer ☐Injecting Drug Use ☐ Nausea ☐ Pneumonia ☐ Shingles ☐ Ulcerative Colitis ☐Intellectual Impairment ☐ Neck Injury ☐ Pneumothorax ☐ Shoulder / Clavicle Repair ☐ Urinary Catheter ☐Internal Defibrillator ☐ Neck Pain ☐ Post Natal Depression ☐ Skin Cancer ☐ Urinary Tract Infection ☐Irritable Bowel ☐ Nephrectomy ☐ Post Partum Haemorrhage ☐ Skin Problems ☐ Urine Retention ☐Ischaemic Heart Disease ☐ Obesity ☐ Pre-Eclampsia ☐ Sleep Apnoea ☐ Vaccination / Immunisation ☐Kidney Transplant ☐ Oesophageal Varices ☐ Pregnancy ☐ Spasm/s ☐ Vaginal Bleeding ☐Knee Replacement / Repair ☐ Oesophagitis ☐ Pregnancy Induced ☐

Hypertension ☐ Spina Bifida ☐ Varicose Veins ☐Laminectomy ☐ Osteoporosis ☐ Prostate Cancer ☐ Spinal Fusion ☐ Ventricular Shunt ☐Leg Pain ☐ Other - Specify ☐ Prostate Problem ☐ Spinal Injury ☐ Ventricular Tachycardia ☐Leukaemia ☐ Ovarian Cancer ☐ Post-Traumatic Stress Dis. ☐ Splenectomy ☐ Vertigo ☐Liver Cancer ☐ Ovarian Cyst ☐ Psychiatric Problem ☐ Spontaneous Abortion ☐ Violent Behaviour ☐Liver Disease ☐ Pacemaker - Permanent ☐ Pulmonary Embolus ☐ Stroke ☐ Vision Impairment ☐Liver Failure ☐ Pacemaker - Temporary ☐ Pyrexia (Unknown Origin) ☐ Supraventricular Tachycardia ☐ Weight Loss ☐Liver Transplant ☐ Pain - Other / Not Listed ☐ Quadriplegia ☐ Systemic Lupus Erythematosus ☐ Wound Infection ☐Lung Cancer ☐ Palpitations ☐ Rectal Bleeding ☐ Surgery - Other / Not Listed ☐



Description Justification for this requestCurrent medications Captures any recorded medicationsRisk factors As below: Click here to enter text.Indicate required fields: Nil Known Click here to enter text.

Age Click here to enter text.Alcohol Abuse Click here to enter text.Diabetes Click here to enter text.Drug Abuse Click here to enter text.Family History Click here to enter text.Hypercholesterolaemia Click here to enter text.Hypertension Click here to enter text.Infectious Disease Risk Click here to enter text.Obesity Click here to enter text.Occupational Click here to enter text.Other - Specify Click here to enter text.Smoker Click here to enter text.Unknown Click here to enter text.

Case HistoryCase nature Paramedic determined main problems

Justification for this request:Click here to enter text.Click here to enter text.

Indicate required fields: Nil Problem ☐ Foreign Body ☐Unknown Problem ☐ Gastrointestinal Problem ☐Alcohol Requesting Detox ☐ Genitourinary Problem ☐Alcohol Withdrawal ☐ Hanging ☐Allergy ☐ Immune Problem ☐Animal Related Injury - Other ☐ Inhalation ☐Assault ☐ Lightning Strike ☐Bicycle Collision ☐ Medical - General ☐Biological Exposure ☐ Motorcycle Collision ☐Bite / Sting / Envenomation ☐ Motor Vehicle Collision ☐Cardiovascular Problem ☐ Musculoskeletal Problem ☐Chemical Exposure ☐ Neurological Problem ☐Crush ☐ Obstetrics / Gynaecology Problem ☐Dermatology Problem ☐ Oncology Problem ☐Drowning / Immersion ☐ Other - Specify ☐Drug Requesting Detox ☐ Overdose / Exposure ☐Drug Withdrawal ☐ Pedestrian Collision ☐Electrical Contact ☐ Psychiatric Problem ☐Emotional Problem ☐ Radiation Contamination ☐Endocrine Problem ☐ Respiratory Problem ☐ENT Problem ☐ Shooting ☐Environmental Exposure ☐ Social Situation Problem ☐Explosion / Incendiary Device ☐ Sporting Injury ☐Eye Injury / Problem ☐ Stabbing ☐Fall ☐ Struck By Object ☐Fire / Smoke Exposure ☐ Surgical - General ☐

Case description Free text description of case-related eventsRequired? ☐




DescriptionOn arrivalScene findings Dangers, patient position, social situation, ethnicity


Others at scene All others at scene on arrival (e.g. Police, family, GP)Required? ☐


Prior care management Activities occurring prior to paramedic arrival


Indicate required fields: Unknown ☐Airway Management ☐Cervical Collar/Spine Immobilisation ☐Chest Compressions ☐Compression Bandage ☐Cooling ☐Defibrillation Prior to Ambulance ☐ECG ☐Expired Air Resuscitation ☐Haemorrhage Control ☐Heat Pack ☐Massage / Stretching ☐Medication ☐No Prior Care ☐Oxygen Therapy ☐Position ☐RICE ☐Splint / Sling ☐Ventilation – Manual ☐Witnessed Arrest ☐Other - Specify ☐

Patient complaintIndicate required fields Justification for this request:Nil Complaint Reported ☐ Depression ☐ Hallucinations ☐ Neck Stiffness ☐ Suicidal ☐Unknown Problem ☐ Diarrhoea ☐ Headache ☐ Noisy Breathing ☐ Suicide Attempt ☐Agitation ☐ Difficulty Standing ☐ Heart Burn ☐ Not Speaking ☐ Swallowing Problems ☐Alcohol / Drug Use ☐ Discharge ☐ Hiccups ☐ Obvious Death ☐ Sweating ☐Alcohol Withdrawal ☐ Discomfort ☐ Hives ☐ Oliguria ☐ Swelling ☐Altered Sensation ☐ Disoriented ☐ Hoarse Voice ☐ Other - Specify ☐ Swollen Glands ☐Anxiety ☐ Distension ☐ Homeless ☐ Pain ☐ Swollen Joint ☐Behavioural Change ☐ Dizzy ☐ Hunger ☐ Palpitations ☐ Swollen Limb ☐Bite / Sting / Envenomation ☐ Domestic Conflict ☐ Hyperventilation ☐ Panic ☐ Tenderness ☐Bleeding - Arterial ☐ Drooling ☐ Inadequate Resource for Care ☐

Requirement ☐ Post Partum Bleeding ☐ Thirst ☐Bleeding - Venous ☐ Drowsy ☐ Incontinence ☐ PR Bleeding ☐ Tightness ☐Bleeding - Other / Not Listed ☐ Drug Withdrawal ☐ Insomnia ☐ PV Bleeding ☐ Tinnitus / Ringing ☐Bloating ☐ Dysmenorrhoea ☐ Itch ☐ Rapid Pulse ☐ Tired ☐Body Fluid Contact ☐ Emotional Distress ☐ Jaundice ☐ Rash ☐ Toothache ☐Breathing Problem / Difficulty ☐ Epistaxis ☐ Laceration ☐ Redness ☐ Tremor ☐Bruising / Haematoma ☐ Facial Droop ☐ Lesion ☐ Respiratory Arrest - Suspected ☐ Unable to Self Care ☐Burn/s ☐ Feeling Faint ☐ Light Headed ☐ Ruptured Membranes ☐ Unconscious ☐Cardiac Arrest - Suspected ☐ Fainted ☐ Light Sensitivity ☐ Seizure/s / Convulsion/s ☐ Unwell ☐Childbirth ☐ Feeling Cold ☐ Loss of Hearing ☐ Self Harm Thoughts ☐ Urine Flow / Frequency Problem ☐Chills ☐ Feeling Hot ☐ Loss of Memory ☐ Shaking / Tremor ☐ Urine Retention ☐Choking ☐ Fever ☐ Loss of Power ☐ Shivering ☐ Vertigo ☐Collapse ☐ Flu - Like Symptoms ☐ Loss of Sensation ☐ Short of Breath ☐ Violent Behaviour ☐Confusion ☐ Foreign Body ☐ Loss of Vision ☐ Skin Irritation ☐ Visual Disturbance / Loss ☐Constipation ☐ Goose Bumps ☐ Loss Of Appetite ☐ Skin Lesion ☐ Vomiting ☐Contractions ☐ Haematemesis ☐ Melaena ☐ Sore Throat ☐ Weakness ☐Cough ☐ Haematuria ☐ Migraine/s ☐ Spasm/s ☐ Weight Loss ☐Cramps ☐ Haemoptysis ☐ Movement Problem ☐ Speech Problem ☐ Wheeze ☐Deformity ☐ Haemorrhoids ☐ Nausea ☐ Spinning Out ☐


DescriptionOn examinationPrimary Survey The findings from a preliminary examination, which identifies potentially immediately life threatening issues.Indicate required fields: No immediate life threat Airway ☐ Breathing ☐ Circulation ☐

Response ☐ Cervical spine ☐ Ventilation ☐ Haemorrhage check ☐

Justification for this request:

Click here to enter text.Click here to enter text.

Secondary survey The findings from ‘head to toe’ examination. Select from REFERENCE TABLE 2, page 11


AssessmentInitial assessment The patient’s main problem as determined by the paramedic. Select from REFERENCE TABLE 3, page 12.


Primary assessment Paramedics select only one as per RERERENCE TABLE 3, page 12. Please print second copy of TABLE 3 if required ‘Primary’ assessment variables differ from selected Initial Assessment fields.


Secondary assessment Any secondary concerns – may be many or none. Select from REFERENCE TABLE 3, page 12. Please print another copy of TABLE 3 if required Secondary Assessment variables differ from selected Initial or Primary Assessment fields.



REFERENCE TABLE 2: Secondary SurveyNo Abnormality Detected ☐ Dislocation ☐ Itch ☐ Rash ☐No Other Abnormalities Detected ☐ Distension ☐ Jaundice ☐ Redness ☐Unknown / Not Assessed ☐ Dizzy ☐ Joint Stiffness ☐ Reduced Movement ☐Abrasion / Graze ☐ Drooling ☐ Joint Warmth ☐ Retrograde Amnesia ☐Altered Conscious State ☐ Drowsy ☐ Laceration ☐ Response - MSA ☐Alcohol Involved ☐ Drug Paraphernalia Present ☐ Lacrimation / Tearing ☐ Rigidity ☐Altered Sensation ☐ Dry Mucosa ☐ Lethargy ☐ Rigor Mortis ☐Amputation ☐ Dysphagia ☐ Light Headed ☐ Seizure/s / Convulsion/s ☐Anxiety ☐ Engorged Neck Veins ☐ Ligature Marks ☐ Shivering ☐Aphasia ☐ Epistaxis ☐ Limb Rotation ☐ Short of Breath ☐Appearance ☐ Erythema / Reddening ☐ Limb Shortening ☐ Skin - Localised ☐Ascites ☐ Evisceration ☐ Limb Threatening Injury ☐ Skin Turgor ☐Aspiration ☐ Extremity - Movement ☐ Loss Of Appetite ☐ Soot In Mouth / Airway ☐Avulsion ☐ Extremity - Sensation ☐ Loss of Function ☐ Sore Throat ☐Behaviour ☐ Extremity - Temperature ☐ Lump ☐ Spasm/s ☐Bite Mark ☐ Eye Movement ☐ Mass ☐ Speech ☐Bleeding - Arterial ☐ Facial Expression ☐ Melaena ☐ Sputum ☐Bleeding - Venous ☐ Fatigue ☐ Mood ☐ Stiffness ☐Bleeding -Other/Not Listed ☐ Fever ☐ Mottled Skin ☐ Sting Mark ☐Blister(s) ☐ Flaccidity ☐ Mucosa ☐ Surgical Emphysema ☐Breath ☐ Foreign Body ☐ Nausea ☐ Sweating ☐Bruising / Haematoma ☐ Fracture/s ☐ Neatness ☐ Swelling ☐Burn/s ☐ Groaning ☐ Neck Stiffness ☐ Swollen Glands ☐Cataract/s ☐ Grunting ☐ Neck Veins ☐ Teeth Missing ☐Cellulitis ☐ Guarding ☐ Necrosis ☐ Thirst ☐Childbirth - Actual ☐ Haematemesis ☐ Neuro Facial Droop ☐ Thought ☐Childbirth - Labour ☐ Haemoptysis ☐ Neuro Grips ☐ Tinnitus / Ringing ☐Cleanliness ☐ Haemorrhoids ☐ Neuro Speech ☐ Trachea ☐Concentration ☐ Headache ☐ Neurovascular ☐

Observations ☐ Tremor ☐Constipation ☐ Hearing Loss ☐ Not Speaking ☐ Unconscious ☐Cough ☐ Hemiplegia ☐ Nystagmus ☐ Unnatural Movement ☐Cramps ☐ Hemiparesis ☐ Oedema ☐ Unsteady Gait ☐Crepitus ☐ Hiccups ☐ Other ☐ Urinary Problems ☐Crying / Tearful ☐ Hoarse Voice ☐ Pain ☐ Vertigo ☐Cyanosis ☐ Hyperventilation ☐ Palpitations ☐ Visual Disturbance / Loss ☐Deformity ☐ Impaled ☐ Perceptions ☐ Vomiting ☐Degloving ☐ Incontinence ☐ Photosensitivity ☐ Weakness ☐Diaphoretic ☐ Inflammation ☐ Poor Short Term Memory

☐ Weight Bearing ☐Diarrhoea ☐ Injection Marks ☐ Postmortem Lividity ☐ Wound / Puncture ☐Discharge ☐ Insight ☐ Pregnancy ☐Discolouration ☐ Irregularity ☐ Pulseless Limb ☐


REFERENCE TABLE 3: AssessmentPrimary assessment - paramedics select only one main conditionSecondary assessment – paramedics can select none or many secondary conditionsFinal assessment - paramedics can select none or manyRevised assessment – main problem after examination

No Problem Identified Select. Choose an item.Constipation

Select.

Choose an item.Unknown Problem

Select. Choose an item.Cough Select.

Choose an item.Abdominal Aortic Aneurysm

Select. Choose an item.Cramps Select.

Choose an item.Abdominal Distension

Select. Choose an item.Croup Select.

Choose an item.Abrasion / Graze

Select. Choose an item.Deceased

Select.

Choose an item.Acute Coronary Syndrome

Select.Choose an item.Decompression Illness

Select.

Choose an item.Acute Myocardial Infarction

Select. Choose an item.Deep Vein Thrombosis

Select.

Choose an item.Acute Pulmonary Oedema

Select. Choose an item.Dehydration

Select.

Choose an item.Airway Obstruction

Select. Choose an item.Depression

Select.

Choose an item.Allergic Reaction

Select. Choose an item.Diarrhoea

Select.

Choose an item.Altered Conscious State

Select. Choose an item.Diplopia Select.

Choose an item.Amputation

Select. Choose an item.Dislocation

Select.

Choose an item.Anaphylaxis

Select. Choose an item.Dizzy Select.

Choose an item.Angina Select. Choose an item.Dysuria Select.

Choose an item.Anxiety Select. Choose an item.Ear Problem

Select.

Choose an item.Aortic Dissection

Select. Choose an item.Eating Disorder

Select.

Choose an item.Arrhythmia

Select. Choose an item.Ectopic Pregnancy

Select.

Choose an item.Asthma Select. Choose an item.Emotional Distress

Select.

Choose an item.Asymptomatic

Select. Choose an item.Epiglottitis

Select.

Choose an item.Avulsion

Select. Choose an item.Epistaxis

Select.

Choose an item.Blister(s)

Select. Choose an item.Eye Injury / Problem

Select.

Choose an item.Bowel Obstruction

Select. Choose an item.Face Injury / Problem

Select.

Choose an Select. Choose an item.Faint Select.


item.BronchiolitisChoose an item.Bronchitis

Select. Choose an item.Febrile Select.

Choose an item.Bruising / Haematoma

Select. Choose an item.Feed Tube Problem

Select.

Choose an item.Burn/s Select. Choose an item.Flail Chest

Select.

Cardiac Arrest Select. Choose an item.Fracture/s

Select.

Choose an item.Cardiac Failure

Select.Choose an item.Gastrointestinal Problem

Select.

Choose an item.Cellulitis

Select. Choose an item.Haematemesis

Select.

Choose an item.Chest Infection

Select. Choose an item.Haematuria

Select.

Choose an item.Childbirth

Select. Choose an item.Headache

Select.

Choose an item.Chronic Obstructive Pulmonary Disease

Select. Choose an item.Head Injury

Select.

Choose an item.Collapse

Select. Choose an item.Hearing Loss

Select.

Choose an item.Compartment Syndrome

Select. Choose an item.Heat Stress

Select.

Choose an item.Confusion

Select. Choose an item.Heat Stroke

Select.

Choose an item.

REFERENCE TABLE 3: AssessmentPrimary assessment - paramedics select only one main conditionSecondary assessment – paramedics can select none or many secondary conditionsFinal assessment - paramedics can select none or manyRevised assessment – main problem after examination

Hyperglycaemia Select. Choose an item.Renal Failure

Select.

Choose an item.Hypertension

Select. Choose an item.Respiratory Arrest

Select.

Choose an item.Hyperventilation

Select. Choose an item.Respiratory Failure

Select.

Choose an item.Hypoglycaemia

Select.Choose an item.Respiratory Tract Infection

Select.

Choose an item.Hypotension

Select.Choose an item.Seizure/s / Convulsion/s

Select.

Choose an item.Hypothermia

Select. Choose an item.Sepsis Select.


Choose an item.Implantable Defibrillator Problem

Select. Choose an item.Short of Breath

Select.

Choose an item.Incontinence - Faecal

Select. Choose an item.Sleep Disorder

Select.

Choose an item.Incontinence - Urinary

Select. Choose an item.Social Problem

Select.

Choose an item.Infection - Other / Not Listed

Select. Choose an item.Soft Tissue Injury

Select.

Choose an item.Intracranial Haemorrhage

Select. Choose an item.Spasm/s

Select.

Choose an item.Joint Effusion

Select. Choose an item.Spinal Cord Injury - Suspected

Select.

Choose an item.Laceration

Select. Choose an item.Strain / Sprain

Select.

Choose an item.Melaena

Select. Choose an item.Stroke Select.

Choose an item.Meningococcal Septicaemia (Possible)

Select.Choose an item.Subarachnoid Haemorrhage

Select.

Choose an item.Migraine/s

Select. Choose an item.Sunburn

Select.

Choose an item.Mobility Problem

Select. Choose an item.Surgical Emphysema

Select.

Choose an item.Nausea Select.Choose an item.Suspected Internal Haemorrhage

Select.

Choose an item.Other - Specify

Select. Choose an item.Swollen Joint

Select.

Choose an item.Pacemaker Problem

Select. Choose an item.Swollen Limb

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Choose an item.Pain Select. Choose an item.Tension Pneumothorax

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Choose an item.Palpitations

Select. Choose an item.Throat Infection

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Choose an item.Panic Attack

Select. Choose an item.Throat Problem

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Choose an item.Pneumonia

Select. Choose an item.Toothache

Select.

Choose an item.Pneumothorax

Select.Choose an item.Transient Ischaemic Attack

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Choose an item.Post Ictal

Select. Choose an item.Unconscious

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Choose an item.Post Immersion

Select. Choose an item.Urinary Catheter Problem

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Choose an item.Post Loss of Consciousness

Select. Choose an item.Urinary Tract Infection

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Choose an item.Psychiatric Episode

Select. Choose an item.Urine Retention

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Choose an item.PR Bleeding

Select. Choose an item.Vertigo Select.

Choose an item.Pulmonary Aspiration

Select. Choose an item.Visual Disturbance / Loss

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Choose an item.Pulmonary Embolism

Select. Choose an item.Vomiting

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Choose an item.PV Bleeding

Select. Choose an item.Weakness

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Choose an item.Rash Select. Choose an item.Wound Inflammation / Infection

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Choose an item.Renal Calculi / Colic

Select. Choose an item.Wound / Puncture

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Choose an item.


Description Required? Justification for this request

Vital Signs Survey (VSS)Time Of observation ☐ Click here to enter text.Pulse Beats/minute ☐ Click here to enter text.

Blood pressure Systolic/Diastolic or palpable ☐ Click here to enter text.

Respiratory rate Breaths/minute ☐ Click here to enter text.

Pain (score) 00 = No pain10 = Worst pain ☐ Click here to enter text.

Temperature oC ☐ Click here to enter text.Route ☐ Click here to enter text.Blood sugar level (BSL) mmol/l ☐ Click here to enter text.Skin ☐ Click here to enter text.Temperature ☐ Click here to enter text. Colour ☐ Click here to enter text. Moisture ☐ Click here to enter text.Glasgow Coma Score (GCS) Total/15 ☐ Click here to enter text.Eye Opening /4 ☐ Click here to enter text.Verbal Response /5 ☐ Click here to enter text.Best Motor Response /6 ☐ Click here to enter text.Pupils (L/R) ☐ Click here to enter text.Size mm ☐ Click here to enter text.Reactivity to light Yes, no ☐ Click here to enter text.APGAR score for newborns Total/10 ☐ Click here to enter text.Appearance 0-2 ☐ Click here to enter text.Pulse 0-2 ☐ Click here to enter text.Grimace 0-2 ☐ Click here to enter text.Activity 0-2 ☐ Click here to enter text.Respiratory effort 0-2 ☐ Click here to enter text.Electrocardiograph (ECG) ☐ Click here to enter text.Rate Beats/minute ☐ Click here to enter text.Rhythm Heart rhythm ☐ Click here to enter text.Blocks Type (e.g. LBBB) ☐ Click here to enter text.Ectopy Type ☐ Click here to enter text.Ischaemia Cardiac location ☐ Click here to enter text.Oxygen saturation (SpO2) % ☐ Click here to enter text.oxygen/air Select ☐ Click here to enter text.End tidal CO2 ☐ Click here to enter text.mmHg ☐ Click here to enter text.Waveform Description ☐ Click here to enter text.Respiratory status Degree of distress ☐ Click here to enter text.

Paediatric vital signs Includes child pain score ☐ Click here to enter text.


Management: Procedures and medications. Indicate required fields in TABLE belowJustification for this request:Click here to enter text.Click here to enter text.Abdominal Thrusts (Adult) ☐ Dressing - Wound / Burns

Cover ☐ Isoprenaline Hydrochloride ☐ Paracetamol 500mg/Codeine 30mg ☐Activated Charcoal ☐ Enoxaparin Sodium ☐ Ketamine ☐ Parecoxib Sodium ☐Adenosine ☐ Extracorporeal Membrane

Oxygenation ECMO ☐ Laryngeal Mask Airway ☐ Pethidine Hydrochloride ☐Adrenaline ☐ Extrication ☐ Lateral Chest Pressure ☐ Phenytoin ☐Advice to Patient/Carer - Specify ☐ Ergometrine ☐ Lateral Chest Thrust (Paed) ☐ Potassium Chloride ☐Airway Clearance ☐ Fentanyl ☐ Lignocaine ☐ Position ☐Amiodarone ☐ Fexofenadine ☐

Hydrochloride ☐ Magnesium Sulphate ☐ Prasugrel ☐Apnoea (Prescribed) ☐ Frusemide ☐ Mannitol ☐ Pre Cordial Thump ☐Arterial Line ☐ Gastric Tube ☐ MAST ☐ Prochlorperazine ☐Aspirin ☐ Glucose - Oral ☐ Mental Health - EEO

Completed ☐ Promethazine ☐Assistance Only ☐ Glucagon ☐ Metaraminol Bitartrate ☐ Propofol ☐Atracurium ☐ Glucose 5% ☐ Methoxyflurane ☐ Restraints Applied ☐Atropine Sulphate / Obidoxime Chloride ☐ Glucose 10% ☐ Metoclopramide ☐ Restraints Removed ☐Atropine ☐ Glucose 50% ☐ Metoprolol ☐ Reassurance Provided ☐Back Blows ☐ Glyceryl Trinitrate ☐ Midazolam ☐ Resuscitation Ceased ☐Balloon Pump ☐ Haemorrhage Control ☐ Misoprostol ☐ RICE ☐Benztropine ☐ Haloperidol ☐ Morphine Sulphate ☐ Rocuronium ☐Benzylpenicillin Sodium ☐ Hartmanns ☐ Midazolam / Morphine

Infusion ☐ Salbutamol ☐Blood Product ☐ Helmet Removal ☐ Naloxone Hydrochloride ☐ Sling ☐Box Jellyfish Antivenom ☐ Heparin ☐ Nasopharyngeal Airway ☐ Sodium Bicarbonate 8.4% ☐Calcium Chloride 10% ☐ Humidicrib / Portacot ☐ Nitrous Oxide / Oxygen ☐ Spinal Immobilisation ☐Calcium Gluconate 10% ☐ Hydrocortisone Sodium

Succinate ☐ Nifedipine ☐ Splint ☐Ceftriaxone ☐ Hypertonic Saline 7.5% ☐ Noradrenaline ☐ Suxamethonium Chloride ☐Central Venous Access ☐ Hypertonic Saline 20% ☐ Normal Saline ☐ Synch Cardioversion ☐Chest Thrusts ☐ Ibuprofen ☐ Ondansetron ☐ Tenecteplase ☐Childbirth ☐ Ice Pack/s ☐ Oropharyngeal Airway ☐ Tension Pneumothorax Needle Test ☐Clopidogrel hydrogen sulfate ☐ Infection Control Measures -

Pt Based ☐ Oseltamivir ☐ Thoracostomy ☐Compression Bandage ☐ Influenza Virus Vaccine ☐ Other Equipment ☐ Tirofiban ☐Continuous Positive Airway Pressure CPAP ☐ Insulin ☐ Other Medication ☐ Trial Equipment ☐CPR ☐ Intercostal Catheter ☐ Other - Specify ☐ Urinary Catheter ☐Cricothyroidotomy ☐ Intraosseous Needle ☐ Other Therapeutic Procedure

☐ Valsalva Manoeuvre ☐Defibrillation ☐ Intubation ☐ Oxygen Therapy ☐ Vecuronium ☐Dexamethasone ☐ Intubation Check ☐ Oxymetazoline ☐

hydrochloride ☐ Ventilation - Manual

Diazepam ☐ Ipratropium Bromide ☐ Oxytocin ☐ Ventilation - Mechanical ☐Dobutamine ☐ Irrigation ☐ Pacing ☐ Verapamil Hydrochloride ☐Dopamine ☐ IV Access ☐ Pancuronium Bromide ☐ Vinegar ☐

Paracetamol ☐ Wheelchair ☐

Revised assessment Assessment following examination. RERERENCE TABLE 3, page 12. Please print another copy of TABLE 3 if required Revised Assessment variables differ from selected Initial, Primary or Secondary


Assessment fields.


Protocols: Paramedics select one chief protocol / one or many associated protocols. Indicate required fields in TABLE below

Justification for this request: Click here to enter text.Click here to enter text.Foundation care M20 Gastroenteritis ☐ T7 Limb injuries and fractures ☐ S3 Mental health emergency ☐

A1 Principles pre-hospital care ☐ M21 Hypoglycaemia ☐ T8 Penetrating trauma ☐ S4 Assault/sexual assault ☐

A2 Basic patient care ☐ M22 Hyperglycaemia ☐ T9 Pelvic injuries ☐ S6 Suicide risk asses manage ☐

A3 Informed consent, capacity, competency ☐ M23 Sepsis ☐ T10 Traumatic hypovolaemia ☐ S8 Elderly at risk ☐

A4 Medication administration ☐ M24 Adrenal crisis ☐ T11 Soft tissue face and neck ☐ S9 Palliative care ☐

A5 Recognition sick baby child ☐ M25 Medical hypoperfusion-hypovolaemia ☐ T12 Burns ☐ Drug/toxicology

A6 Pain management ☐ Cardiac/cardiovascular T13 Eye injuries ☐ D1 Drug overdose poisoning ☐A7 Patient management ☐ C1 Acute coronary syndrome

☐ T14 Electric shock ☐ D2 Organophosphate poison ☐

A8 Urgent transport ☐ C2 Resuscitation decision algorithm ☐ T15 Trapped patient ☐ D3 Alcohol intoxication ☐

A9 Bariatric patients ☐ C3 Cardiac arrest ☐ T16 Limb realignment, difficult extrication ☐

D4 Oleoresin capsicum spray exposure ☐

Medical C5 Cardiogenic pulmonary oedema ☐

T16A Limb realignment, difficult extrication – Ketamine ☐ D5 Nerve agent poisoning ☐

M1 Abdominal conditions ☐ C6 Cardiogenic shock ☐ T17 Deteriorating trauma patient ☐ Obstetrics/newborn

M2 Airway obstruction foreign body ☐ C7 Bradycardia ☐ T18 Wound care ☐ O1 Obstetric general protocol ☐

M4 Asthma ☐ C8 Tachycardia ☐ T19 Falls in the elderly ☐ O2 Pregnancy related PV haemorrhage ☐

M6 Nausea & Vomiting ☐ C9 Hyperkalaemia ☐ T20 Traumatic cardiac arrest ☐ O3 Postpartum haemorrhage ☐M7 Croup ☐ C11 Stroke ☐ Environment/envenomation O4 Prolapsed umbilical cord ☐

M8 Dehydration ☐ C12 Cardiac reperfusion – Primary angioplasty ☐

E1 Chemical biological radiological (CBR)/HAZMAT ☐

O5 Pregnancy related hypertension ☐

M9 Seizures ☐ C13 Cardiac reperfusion – Prehospital thrombolysis ☐ E2 Diving emergencies ☐ O6 Newborn care ☐

M13 Meningococcal septicaemia ☐ Trauma E3 Hyperthermia ☐ Patient transport decisions

M14 Respiratory distress ☐ T1 Major trauma ☐ E4 Hypothermia ☐ P1 Authorised care ☐

M15 Autonomic dysreflexia ☐ T2 Multiple victim situations ☐ E5 Drowning ☐ P2 Patient refuses paramedic

advice ☐

M16 Anaphylaxis, allergic ☐ T3 Helicopter operations – major trauma – “Primary” ☐ E6 Bites and Envenomation ☐ P5 Referral decision ☐

M17 Epistaxis ☐ T4 Head injuries ☐ E7 Smoke noxious gas, carbon monoxide poisoning ☐

P6 Incident control another agency ☐

M18 Dental problems ☐ T5 Spinal injuries ☐ Specialised care P7 Non transport – Non health issues ☐


M19 COPD ☐ T6 Chest injuries ☐ S1 Home dialysis emergency ☐


Description Required? Justification

RTA Road traffic accident detailsDetails of vehicle ☐ Click here to enter text.Vehicle type ☐ Click here to enter text.State ☐ Click here to enter text.Vehicle registration ☐ Click here to enter text.Motor cyclist details Cyclist or motorbike ☐ Click here to enter text.Impact type ☐ Click here to enter text.Helmet status ☐ Click here to enter text.Helmet damage ☐ Click here to enter text.Mode of impact ☐ Click here to enter text.Other vehicle ☐ Click here to enter text.Vehicle safety details Seat belt, airbags etc. ☐ Click here to enter text.Vehicle impact details Speed, direction, damage ☐ Click here to enter text.Patient information Crushed, trapped, ejected etc. ☐ Click here to enter text.


Description Required? JustificationBilling

Billing type

Section 20, pensioner type, police custody etc.

☐Click here to enter text.Click here to enter text.Click here to enter text.

ResultPatient not treated Reason ☐ Click here to enter text.Patient not transported Reason ☐ Click here to enter text.

Final assessment

Problem at time of paramedic discharge

RERERENCE TABLE 3, page 12

Referral Specialised Medical Service Click here to enter text.Indicate required fields: Assessment Team Click here to enter text.

Doctor Click here to enter text.Patient Click here to enter text.Social Worker Click here to enter text.Case Worker Click here to enter text.000 Referral Service Click here to enter text.Other Team Click here to enter text.NETCOM Click here to enter text.Other Health Professional Click here to enter text.Police Click here to enter text.Drug Referral Service Click here to enter text.Detox Service Click here to enter text.Family Click here to enter text.Other - Specify Click here to enter text.

Observed outcome Unknown Click here to enter text.Indicate required fields: Dead on arrival Click here to enter text.

Died at scene Click here to enter text.Died en route Click here to enter text.Died in ED/hospital Click here to enter text.ROSC at hospital Click here to enter text.

Major trauma criteria? Protocol T1 ☐ Click here to enter text.Final odometer ☐ Click here to enter text.Total trip odometer ☐ Click here to enter text.Transport reason Reason Click here to enter text.

Transport codeE.g. ‘lights & sirens’ from scene

☐ Click here to enter text.

Time Load time ☐ Click here to enter text.

Date post:	30-Mar-2018
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