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