ALCOHOL and YOUNG PEOPLE Audit Proforma

Family name: ______First Name: ______

Case note number: CHI number: Audit no:

  .

Alcohol & Young People Hospital code: Audit no: .

Postcode: Sex:1 = Male 2 = Female Age: .

Enter the ED: Date: .. Time: . Seen in Resus:  0 = no 1 = yes

Referred by:  1 = self 2 = GP 3 = NHS 24 4 = Police 5 = friends/family 6 = voluntary services 7 = school

8 = other 9 = not known specify: ______

Arrived by:  1 = self 2 = SAS 3 = Police 4 = other specify: ______

Accompanied:  0 = no 1 = yes 2 = not documented if yes, specify: ______

Presenting Complaint: 1 = Cardiac 2 = CNS 3 = Respiratory 4 = Psychiatric 5 = GI 6 = Alcohol 7 = Trauma

8 = other 9 = Collapse specify: ______

Trauma – mechanism of injury: 1 = MVA (driver/passenger) 2 = Pedestrian 3 = Assault 4 = Fall over 2m 5 = Fall 2m or under

6 = Sport 7 = other specify: ______

Evidence of self-harm:  0 = no 1 = yes 2 = not documentedspecify: ______

Living Arrangements: 0 = not documented 1 = alone 2 = with parent(s) 3 = with other relative(s) 4 = with friends

5 = looked after & accommodated 6 =homeless 7 = roofless 8 = other specify:______

Use of Alcohol:

Are there alcohol-related problems in the patient’s PMH?  0 = no 1 = yes 2 = not documented

This episode:

Has the patient consumed alcohol in the previous 24 hours?  0 = no 1 = yes 2 = not documented

Type of alcohol consumed:  0 = not documented 1 = spirits 2 = beer/lager 3 = cider 4 = fortified wines 5 = wines

6 = Alcopops 7 = combination NFS

Number of units: .

How was the alcohol obtained?  0 = not documented 1 = given 2 = bought for them 3 = bought self 4 = from house

5 = other specify: ______

Had the carer consumed alcohol in the previous 24 hours?  0 = no 1 = yes 2 = not documented 3 = not applicable

YP1

Use of Drugs:

Has the patient taken other substances in the previous 24 hours?  0 = no 1 = yes 2 = not documented

If yes, what was the intention?  0 = not documented 1 = recreation 2 = deliberate self-harm 3 = accidental self-harm

4 = other specify: ______

Are there other substance problems in the patient’s PMH?  0 = no 1 = yes 2 = not documented

Further Management:

Referred to: Specialty  Alcohol Liaison Nurse CHPN  OPD Appointment  0 = no 1 = yes 2 = not known

Leave ED date: .. Leave ED time: :

Disposal from the ED: 

1 = Home 2 = SSW 3 = Assessment/CDU 4 = Medical 5 = Surgical 6 = Ortho 7 = GI 8 = ICU 9 = HDU 10 = Maxillo-facial

11 = Neurosurgery 12 = Irregular discharge 13 = Police 14 = Mortuary 15 = Psychiatric Unit 16 = Specialist NHS treatment

17 = Community non-NHS counselling service 18 = did not wait 19 = Paediatric ward

Accompanied at discharge?  0 = no 1 = yes 2 = not documented3 = not applicable

Counselling given prior to discharge from the ED?  0 = no 1 = yes 2 = not documented 3 = not applicable

Discharge plan from the ED:     

0 = not recorded 1 = none 2 = GP 3 = CPN/ALN 4 = Psychiatric OPD 5 = Community Paediatrics

6 = Child & Adolescent Mental Health Team 7 = School Nurse 8 = Voluntary Agency 9 = Social Work

10 = other specify: ______

Is there documented evidence of abuse to staff in the ED: verbal:  physical:  0 = No 1 = yes