Comes with me to every job, gets to know all my patient details, get flung around in the back of the van, falls on the floor, spills its contents around, only to be picked up by an angry owner (me) and getting shoved back together in one place. It's predecessor was green (funky!), but sadly died a slow death of maltreatment. Everyday office folders aren't made for everyday ambulance abuse I guess.
Anyway, point to be made is the content. Have a look at the inside sleeve, that's my main reminder of what I want to write on my Patient Care Record form, on the other side is a quick trauma assessment sheet.
This is the Main Page:
Crafted and finetuned after 15 months of experience (with hopefully many more years to come!), continually added information as experience expands, this is the heart and sole of my paperwork. Generally the procedure consists of doing a job, documenting as much as possible and needed, handing over at hospital, remembering questions that I had no answer for (I once forgot to check for a tonguebite and incontinence in a seizure patient). These improvements make their way on to the sheet, which eventually make their way in to my brain, sheet more of a backup plan for doozy days or 3am jobs. Only recently (3-4 weeks ago) did I add the OPQRST to my repertoire, which has made Chest Pain and Abdo Pain calls much easier, asking the right questions and getting the documentation right the first time.
To keep posts short (yep Taz, this is for you :), I'll divide my folder explanation up in to two posts.
What do you guys carry around in your folder? Any tips/tricks/hints I could add?
Feel free to use my template (please don't forget to credit me). I can send you a PDF/word/pages version of the document if you like, just let me know in the comments (can only upload pics to blogger).
