MDT Hospital Reporting Procedure

This is the Template of which you are to fill out Hospital Reports in the MDT. Reports should be filled out for every patient that you treat so that we can forward any necessary incidents up your chain of command to be passed onto the police.



Report Title


Patients Full Name



Report Type


Ambulance Report
or
Hospital Report



Report Details

Presenting Complaint (PC)


Why has the Patient come to see you?
Why have you gone to see this Patient?


History of Presenint Complaint (HPC)


When did this Start?
Has the Problem Changed? If so, how?
Any other associated Symptoms?


Past Medical History (PMH)


It is good to ask about any relevant issues in case it is impacting their current problem


Drug History (DH)


Ask about any medication they might be taking, including but not limited to:
Over the counter medications
Contraceptives
Herbal Remedies
Protein shakes


Allergies


Social History (SH)


Home Life? Who is at home, is everyone well?
Smoking? Alcohol? Any other Drugs?
Work Life, Occupation and Role?
Is their Profession Safety Critical Work?
Impact of problem on work role?


Family History (FH)


Any Similar Conditions Run in the Family?


Observations, Examinations and Investigations


Any Treatment Given



Impression / Diagnosis


Most Likely Diagnosis
Other Possible Diagnoses