Downtime - AED Registration Form

Downtime - AED Registration Form

Downtime – AED Registration Form

Objective:

The purpose of this form is to record patient encounter details during a period of planned or unplanned EPR downtime. The completed form will be used to re-enter details into EPR when it becomes available.

Financial Number (FIN):

If you do not know the patient’s MRN, you will require a FIN number. Please contact A&E Reception who will allocate a FIN number. The FIN number is used as a unique patient identifier during downtime if the MRN is unknown and will enable clinicians to order pathology and radiology tests.

Important: Please complete all fields on this form. The areashighlighted in yellow are mandatory.

AUDIT – MANUAL DATA ENTRY
(Please complete upon entering details into EPR after downtime)
Name of User: ______
MRN Allocated: ______
Date Entered in EPR: ______/______/______
Time Recorded in EPR: ______
Comments: ______

REGISTRATION

MRN Number:
NHS Number:
(If known)
FIN Number*: / Allocated by A&E Reception*
Title:
Surname:
First Name:
Date of Birth:(dd/mm/yyyy)
Gender:
Ethnic Category (Please tick as appropriate)
Asian – Any Other Asian Background / Mixed – White and Black African
Asian or Asian British – Bangladeshi / Mixed – White and Black Caribbean
Asian or Asian British – Indian / Other – Any Other Ethnic Group
Asian or Asian British – Pakistani / Other – Chinese
Black – Any Other Black Background / Other – Not Known
Black or Black British – African / Other – Not Stated
Black or Black British – Caribbean / White – Any Other White Background
Mixed – Any Other Mixed Background / White – British
Mixed – White and Asian / White – Irish
Legally resident in UK?
(Please tick as appropriate) / No
Unable to Validate
Yes – Confirmed
Yes - Unconfirmed
GP Details(Please include full name and address)
GP Name:
Surgery Name:
Address / Postcode:
Lead Clinician:
Stream:
(Please tick as appropriate) / Awaiting Stream / Primary Care
Major / Resus
Minor/Injury / Self-Care
N/A / Walk in Centre
Attendance Category:
(Please tick as appropriate) / New Problem/First Attendance
Planned - Follow Up Attendance
Unplanned - Follow Up Attendance
Source of Referral:
(Please tick as appropriate) / Community Dental Service
Dentist
Educational Establishment
Emergency Services
General Practitioner
Health Care Provider (Same or Other)
Local Authority Social Services
Other
Police
Self-Referral
Work
Arrival Mode:
(Please tick as appropriate and complete additional fields highlighted in yellow) / Air Ambulance / ID:
Job #:
Ambulance / ID:
Job #:
Police Vehicle / Police Badge #:
Private Transport
Public Transport / Walk
Other
Reason for Visit:
Incident Type: (Please tick as appropriate)
Assault (Please include description below) / Not Known
Brought in Dead / Other Accident
Deliberate Self-Harm / Other Than Above
Firework Injury / Road Traffic Collision (Please complete further details below)
Major Incident / Sports Injury
Assault Description: (If applicable)
Incident Location: (Please tick as appropriate)
Bar / Educational Establishment
Home / Other
Public Place / Work
Road Traffic Collision Details (Please tick if applicable)
Patient Type: / Vehicle Type: / Seat Belt: / Air Bag:
Cyclist / Bicycle / Fitted and Not Worn / Fitted and Deployed
Driver / Bus/Coach / Fitted and Worn / Fitted and not Deployed
Motorcyclist / Car / Not Fitted / Not Fitted
Not Known / Lorry/Van / Not Known / Not Known
Passenger / Motorcycle
Pedestrian / Not Known
Other
Incident Date: / Incident Time:
Arrival Date: / Arrival Time:
Address and Patient Contact Details
Permanent Address:
Post Code:
Home Number:
Mobile Number:
Consent for SMS?
(Please tick as appropriate) / No
Yes
Patient Copy Letter Consent?
(Please tick as appropriate) / No
Yes
Parent / Guardian(Mandatory for Children)
Relationship to Patient (Please tick as appropriate)
Brother / Parent Unspecified
Carer / Partner
Child / Polygamous
Child/Insured Responsible / Polygamous Partner
Dependent / Proxy - Communication
Father / Proxy - Contact
Foster Parent / Proxy – Contact and Communication
Guardian (other than a parent) / Relative
Mother / Sister
Non Dependent / Spouse
Not Known / Step Parent
Other Next of Kin

Parent / Guardian Details:

Surname:______

First Name:______

Address:______

Post Code:______

Home Phone Number:______

Work Phone Number: ______

Mobile Phone Number:______

If Patient is a Child, are they LookedAfter Child: Yes No

Social Worker:______

School Name and Address:______

______

______

------REGISTRATION COMPLETE------

DISCHARGE / DEPART PROCESS

Diagnosis:______

INVESTIGATIONS & TREATMENTS

Did your patient have any investigations?
(If yes, please complete relevant sections below) / Yes No
POCT / OBSERVATIONS AND MONITORING
Pregnancy Test / Cardiac Monitor
Toxicology / Neuro Observations
Urinalysis / Oximetry/ Sats
OTHER / Vascular Observations
Investigation Other / Vital Signs
Bladder Scan / Observations and Monitoring Other
Ultrasound
Investigation Comments Box:
Did your patient have any Procedures/Treatments or Medications?
(If yes, please complete relevant sections below) / Yes No

PROCEDURES

CRITICAL CARE PROCEDURES / LINES, DRAINS TUBES / MINOR PROCEDURES
Thrombolysis / Arterial Line / Incision and Drainage
Resuscitation/CRP/MajorTrauma / Central Line / Joint Aspiration
Cardioversion / IO Line / Minor Plastic Surgery
Defibrillation / Suprapubic Catheter / Minor Surgery
Pericardiocentesis / Urinary Catheter / Removal of Foreign Body
Cooling (Post Arrest) / Chest Drain / Epistaxis Control
Temporary Transvenous Pacing / NG Tube / Minor Procedures Other
External Pacing / IV Line
Cooling (Temp Control) / Lines / Tubes Other
Blood Transfusion / AIRWAY AND BREATHING / ANAESTHESIA
Lumbar Puncture / Intubation / General Anaesthesia
Rewarming Hypothermic Patient / BiPAP / CPAP / Anaesthetic Local/ Block / Entonox
Aspiration / Rapid SequenceInduction / Sedation
Charcoal / Bag Valve Mask / Anaesthesia Other
Critical Care Procedures Other / Laryngeal Mask
MANIPULATIONS / Nasal/Oral Airway
Manipulation of Upper Limb / Airway and Breathing Other
Manipulation of Lower Limb
Manipulation Other
Procedures Comments Box:

TREATMENTS

EYE TREATMENTS / SPECIALISTS TREATMENTS / SPECIAL CARE TREATMENTS
Subconjunctival Injection / Dental Treatment / OT Activities of Daily Living
Retrobulbar Injection / Specialist Treatments Other / OT Assessment
Epilation of Lashes / MINOR INJURIES TREATMENTS / Physiotherapy Advice
Eye Dressing / Major Dressing / Physiotherapy Treatments
Eye Irrigation / Minor Dressing / Social Work Intervention
Orthoptic Injection / Plaster of Paris / Social Care Treatments Other
Eye Treatments Other / Splint/Surgical Appliance / AHPOther
REVIEW TREATMENTS / Sling/Collar and Cuff / DISCHARGE ADVICE ONLY
Burns Review / Staples / Advice - Verbal
Dressing/ Wound Review / Steri-Strips / Advice- Written
Fracture Review / Support Bandage
Recall/ X-Ray Review / Sutures
Removal of Plaster of Paris / Walking Aid
Removal of Sutures/Clips / Wound Glue
Review Treatments Other / Minor Injuries Treatment Other
Treatments Comments Box:

MEDICATIONS

MEDICATIONS ADMINISTERED / TETANUS ADMINISTRATED
Buccal / Combined Tetanus/ Diphtheria Booster
Ear Drops / Combined Tetanus / Diphtheria Course
Entonox / Human Immunoglobulin
Eye Drops / Immune
Infusion Fluids / Tetanus Toxoid Booster
Intradermal / Tetanus Toxoid Course
Intramuscular
Intravenous Drugs (Stats / Bolus) / THROMBOLYSIS
Intravenous Infusion / Streptokinase
Nebuliser/Spacer / Tenecteplase
Oral / TPA
Oxygen / Thrombolysis Other
Per Rectum
Subcutaneous / PRESCRIPTIONS
Sublingual / Prescription FP10
Topical / Prescription TTA/TTO
Medications Comments Box:
Discharge Outcome / Disposition / Follow-Up (Please tick as appropriate)
Admitted as Inpatient - Same Trust / Discharge to A&E Follow Up
Admitted Same Trust - CDU / Discharge to see District Nurse
Dead on Arrival / Discharge – Refer to Fracture Clinic Same Trust
Did Not Wait for Triage / Discharge – Refer Main Outpatients Same Trust
Did Not Wait to be seen by Doctor / Discharge – to Outpatients Other Trust
Died In Dept / Discharge – Ref to Physio Same Trust
Discharge for GP – to check progress / Refused Treatment
Discharge for GP F/Up– to refer to Outpatient / Seen by Doctor – Left Before Treatment
Discharge for GP – to register with GP / Sent Home via Triage and Advice
Discharge for GP F/Up – to remove sutures / Transfer to Facility in Same Hospital for Advice
Discharge to Primary Care Services / Transfer to Other Trust for Admission
Discharge – No Follow Up

Is the patient safe to go home? Yes No N/A

Has all safeguarding documentation been completed? Yes No

Breach Classification (Please tick as appropriate)
Did not Breach / Wait for bed – Other
Clinical / Wait for bed – Paediatrics
Late Referral / Wait for bed – Side Room
Specialty - Anaesthetic / Wait for bed – Surgical
Specialty – Cardiology / Wait for Diagnostics
Specialty – Care of the Elderly / Wait for Doctor
Specialty – Medicine / Wait for Porter
Specialty – Ophthalmology / Wait for Transport
Specialty – Orthopaedics / Wait for Treatment
Specialty – Other / Wait for Triage
Specialty – Outreach / Mental Health – Crisis Team
Specialty – Outside of Trust / Mental Health - PLN
Specialty – Paediatric / Aw Diagnostics – CT Delay
Specialty – Mental Health / Aw Diagnostics – X-Ray Delay
Specialty – Surgery / Aw Diagnostics – Investigation Delay
Wait for bed – Care of the Elderly / Nurse Delay
Wait for bed – CDU / Speciality Disagree Admission
Wait for bed – Gynae / A&E cubicle blocked due to bed waits
Wait for bed – Medical / A&E cubicle blocked due to volume
Wait for bed – Orthopaedics / Other
Discharge Date:
Discharge Time:
Discharging Staff Member:
Destination:
Decision to Admit(PLEASE COMPLETE IF PATIENT IS TO BE ADMITTED)
Referring Physician:
Decision to Admit Date:
Decision to Admit Time:
Source of Admission: / Usual Place of Residence
Local Authority Foster Home
NHS Care Home
NHS Other Provider
Non NHS Hospital
Non NHS Residential Care
Temporary Home
Lead Clinician(Receiving Location):
Main Specialty:
Treatment Function:

Deceased Information(Please complete Mortuary Process document if applicable)

Deceased Date:______

Deceased Time:______

Death Verified By:______

Deceased ID Method: / Death Certificate
Hospital Records
NHS Central Register Follow Up
Post Mortem
Verbal Communication

------DISCHARGE COMPLETE------

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