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2024年3月20日发(作者：余切函数的性质与图像)

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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:

Home Address:

M / FAge:Seat No:Frequent flyer member?Y/N

DETAILS OF ILLNESS / ACCIDENT

Time/Date of Onset (GMT):

Describe events leading up to incident:

: hrs. / /

Location:

SYMPTOMS & SIGNS

(tick, circle or complete all appropriate boxes)

PAIN:

Site(s):

Character:

Site(s):

Vomiting

Pale

Cold

Confused

Where:

Diarrhoea

Blue

Dizzy

Aggressive

Sharp / Cramping / Aching / Throbbing

Severity:

Pattern:

Severity:

Cough

Flushed

Weakness

Intoxicated

Mild / Moderate / Severe

Constant / Variable

Mild / Moderate / Severe

Breathless or wheezy

Clammy/Sweating

Fit/Convulsion

BLEEDING

Nausea

Faint

Hot/feverish

Anxious

Rash/spots

Other (specify):

INJURY

(tick appropriate box/boxes):

Abrasion

Concussion

Amputation

Cut

Eye

Hand

Pulse: / minute

Temperature:

Other observations:

Fracture

Dislocation

Ear

Finger

Bruising

Sprain

Torso

Leg

Burn

Foreign Body

Back

Foot/toe

Body Part

Head/neck

Arm

OBSERVATIONS:

Blood Pressure: mm/Hg

Respiration: / minute

cut-off-portion

TRANSFER OF CARE TO GROUND MEDICAL SERVICES

Name of Casualty:

Brief Details of Incident:

Date and time of onset:

Oxygen given:

Was casualty unconscious at any time?

Defibrillator applied?

MEDICATION ADMINISTERED:

Drug:

Dose:

YES / NO

YES / NO

YES / NO

If yes, did condition improve?

If yes, were any shocks given?

YES / NO

YES / NO

Time (GMT)

Any other treatment given:

Crew Member name (CAPITALS):

Staff ID:Signature:

SAMPLE MEDICAL INCIDENT REPORT

(To be completed for all incidents)

PATIENT'S MEDICAL HISTORY

DETAILS

Had this problem before?

Taking anymedication?

Any allergies?

Any recent illnesses or operations?

Currently pregnant?

YES / NO

YES / NO

YES / NO

YES / NO

YES / NO

If yes how many months?

CABIN CREW ACTION

(circle or complete as indicated)

Oxygen given?

Medication given? (specify)

Was own medication or from

other passenger used? (specify)

Defibrillator used?

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 Professional

Attempt to contact company doctor:

Port Health Authority advised:

Further information/comments:

Pulse restored?

YES / NO

Successful / unsuccessful

YES / NO

YES / NO

YES / NO

Respiration restored?

YES / NO

Successful / unsuccessful

Successful / unsuccessful

Consciousness regained?

YES / NO

YES / NO

If yes, were any shocks administered?

YES / NO

YES / NO

If yes, did patient's condition improve?

YES / NO

OUTCOME

(tick):

Diversion

Patient left aircraft by wheelchair

Patient recovered before landing

Patient left aircraft by stretcher

First Aid

Ground medical

Fit to fly as passenger

cut-off-portion

Patient walked off aided/unaided

Patient died on aircraft

GP/Appointed Dr

Hospital

Remained in hotel / hospital

Treatment:

None

Crew:

Fit to operate

Transfer of Care to Ground Medical Services

Sample Medical Incident Report


本文标签： 函数 性质 图像 作者

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