SAMBA 2015 – June 25th 2015 DRAFT______/ No on Master list

1. Age

/ years / 2. Sex / M F
3. Dementia Yes NO NK / Delirium Yes NO NK / 4. Clinical Frailty Scale (1-9)
5. Patient admitted from: patient’s own home Residential home Nursing home Other (specify): unknown
6. Date & time of arrival to hospital / / / __:__ / 7. Date & time of arrival to AMU/Ambulatory care / / / __:__
8. Initial referral made by GP ED Other (specify):
9. Actually admitted vial ED AMU Ambulatory Care Other (specify):
10. 1st Review Competent Clinical Decision Maker (Date, Time) / / / __:__

11. Medical Consultant

(Date, Time)

/ / / __:__ / 12. This consultant’s main specialty is
Acute Medicine Cardiology Others: ______

13. 1st set of VITAL SIGNS on admission to Hospital Date & time / / __:__

/

NEWS score (see scoring table over leaf)

Score ≥ than EWS Trigger-Score / YES NO / Critical Care Outreach informed / YES NO N/A
17. Referred to Specialty / YES NO /

Name of Specialty

18. Date & time of Specialty review in AMU / / / __:__ /

Not reviewed in AMU

PRIMARY TRANSFER DESTINATION FROM AMU within 72 hours (tick ONE only)
19. Date & time of discharge/transfer / / / / __:__
20. Discharged to own home / Discharged to residential or nursing home /

Still on the AMU

/ Transferred to another ward
Transferred to a higher level of care (ITU/HDU/CCU) / Transferred to another hospital /

Died

/ Other: ______
21. Is this a readmission: Was patient discharged from hospital within last 28 days prior to the current admission? / YES NO NK / Date / /
INVESTIGATIONS AND OTHER INTERVENTIONS
Stroke
(suspected or confirmed) / YES NO / If yes: CT within 12 hours / YES NO
Pulmonary embolism
(suspected or confirmed) / YES NO /

If yes: VQ scan within 24 hours

/ YES NO

If yes: CTPA within 24 hours

/ YES NO
Upper GI bleed (suspected) / YES NO / If yes: OGD within 24 hours / YES NO
Comments

ED = Emergency Department; GP = General Practitioner;

NK = Not known; N/A = Not applicable

NEWS scoring table (Fig 1)

Clinical Frailty Scale (Fig 2)

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