HTML Preview Medical Assistant Incident Report page number 1.
SAMPLE MEDICAL INCIDENT REPORT
(To be completed for all incidents)
COMPLETED FORM TO BE RETURNED TO:
NAME OF PERSON
COMPLETING FORM: Staff ID:
SECTION 1
Date: / / Flight No: From: To:
PATIENT DETAILS (Complete as applicable)
Name:
Sex: M / F Age: Seat No: Frequent flyer member? Y/N
Home Address:
DETAILS OF ILLNESS / ACCIDENT
Time/Date of Onset (GMT): : hrs. / /
Describe events leading up to incident:
Location:
SYMPTOMS & SIGNS (tick, circle or complete all appropriate boxes)
PAIN:
Site(s):
Character: Sharp / Cramping / Aching / Throbbing Pattern: Constant / Variable
Severity:
Mild / Moderate / Severe
BLEEDING
Site(s):
Severity:
Mild / Moderate / Severe
Nausea
Vomiting
Diarrhoea
Cough
Breathless or wheezy
Faint
Pale
Blue
Flushed
Clammy/Sweating
Hot/feverish
Cold
Dizzy
Weakness
Fit/Convulsion
Anxious
Confused
Aggressive
Intoxicated
Rash/spots
Where:
Other (specify):
INJURY (tick appropriate box/boxes):
Abrasion
Amputation
Fracture
Bruising
Burn
Concussion
Cut
Dislocation
Sprain
Foreign Body
Head/neck
Eye
Ear
Torso
Back
Arm
Hand
Finger
Leg
Foot/toe
Body Part
OBSERVATIONS:
Pulse: / minute
Blood Pressure: mm/Hg
Temperature:
Respiration: / minute
Other observations:
cut-off-portion
TRANSFER OF CARE TO GROUND MEDICAL SERVICES
Name of Casualty:
Date and time of onset:
Brief Details of Incident:
Oxygen given:
YES / NO
Was casualty unconscious at any time?
YES / NO
Defibrillator applied?
YES / NO
If yes, did condition improve?
YES / NO
If yes, were any shocks given?
YES / NO
MEDICATION ADMINISTERED:
Drug:
Dose: Time (GMT)
Any other treatment given:
Crew Member name (CAPITALS):
Staff ID: Signature:
Airline
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