Medical Assistant Incident Report
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/ / Location: Describe events leading up to incident: SYMPTOMS SIGNS PAIN: Site(s): Character: BLEEDING Site(s): Nausea Faint Hot/feverish Anxious Rash/spots Other (specify): (tick, circle or complete all appropriate boxes) Sharp / Cramping / Aching / Throbbing Severity: Pattern: Mild / Moderate / Severe Constant / Variable Severity: Mild / Moderate / Severe Vomiting Pale Cold Confused Diarrhoea Blue Dizzy Aggressive Cough Flushed Weakness Intoxicated Breathless or wheezy Clammy/Sweating Fit/Convulsion (tick appropriate box/boxes): Abrasion Amputation Concussion Cut Fracture Dislocation Bruising Sprain Burn Foreign Body Ear Finger Torso Leg Back Foot/toe Where: INJURY Body Part Head/neck Arm OBSERVATIONS: Eye Hand Pulse: / minute Temperature: Other observations: Blood Pressure: Respiration: mm/Hg / minute cut-off-portion TRANSFER OF CARE TO GROUND MEDICAL SERVICES Name of Casualty: Date and time of onset: Brief Details of Incident: YES / NO YES / NO YES / NO Oxygen given: Was casualty unconscious at any time Defibrillator applied If yes, did condition improve YES / NO If yes, were any shocks given YES / NO MEDICATION ADMINISTERED: Drug: Dose: Time (GMT) Staff ID: Signature: Any other treatment given: Crew Member name (CAPITALS): SAMPLE MEDICAL INCIDENT REPORT (To be completed for all incidents) PATIENT S MEDICAL HISTORY DETAILS YES YES YES YES YES Had this problem before Taking any medication Any allergies Any recent illnesses or operations Currently pregnant CABIN CREW ACTION Oxygen given Medication given (specify) / / / / / NO NO NO NO NO If yes how many months (circle or complete as indicated) YES / NO If yes, did patient s condition improve YES / NO Was own medication or from other passenger used (specify) Defibrillator used YES / NO YES / NO If yes, were any shocks administered Other onboard medical equipment used (specify) Was Cardiopulmonary Resuscitation (CPR) performed YES / NO Use of ground medical control YES / NO Assistance of on-board Dr or Health Pro
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