MOD F TECH 54 Principles of Completing Patient Report Forms

Question 1

What is a PRF?

Answer 1

• A legal document
• A reference document giving concise information about a patient’s history and examination findings at a point in time
• A method of communicating to other professionals important and relevant information

Question 2

Incidents

Answer 2

•Can be used to investigated a number of different issues;

–Complaint

–Clinical negligence claim

–Criminal investigation

–Disciplinary

–The quality of your Patient Report Form may prove to be critical in any of these circumstances

Question 3

Written contents of PRF

Answer 3

• Chief complaint
• Hx of chief complaint
• Relevant PMH
• Monitoring of vital signs (O/M)
• Clinical findings (O/E)
• Working diagnosis, consider differentials Treatment (Rx)
• Social history (Sx)
• Changes enroute

Question 4

Impressions:

Answer 4

• A comment relating to the patient’s overall demeanour is usually helpful.
• If the patient is obviously drunk and obstreperous it should be recorded with a comment such as “ strong smell of alcohol and uncooperative behaviour consistent with alcohol intoxication,” rather than “ obnoxious drunk.”

Question 5

Clarification

Answer 5

• NAD – ensure you record the assessment/s which led to this decision
• Advice given – state what’s been given
• Safety netting – record what has been arranged

Question 6

Golden Rules of Recording PRF information:

Answer 6

• Be legible (Black Biro)
• Contain relevant negative results
• Never use derogatory or insulting terms
• Include results of any investigations
• Record procedures performed
• Record adverse advents
• Not recorded = not done
• Remember, patients have a right to see their medical notes and are frequently used in law

Question 7

Mandatory Information

Answer 7

• All times must be recorded
• Patient monitoring activity
• Second and subsequent monitoring activity
• Drug administration including oxygen
• Resuscitation attempt information
• Refused to travel with the reasons clearly stated
• Crew and vehicle pin and numbers

Question 8

Summary:

Answer 8

• Legal document
• Method of communicating information
• Accuracy paramount
• Can have either a negative or positive effect if your clinical actions are being investigated
• Mandatory information must be recorded