Introduction
Context - Why have a minimum data set?
What is the minimum data set?
What the minimum data set is not
What are the benefits?
What will happen if we do not implement the minimum data set?
The role of the ASA Clinical Effectiveness Project
Conclusion
Minimum data set
 

Minimum Data Set

Publications > Recommended minimum data set >Minimum data set

ASA/JRCALC14/06/99 SN

MINIMUM DATA SET

Form Details
Ambulance Service
Date of Call
Incident Number
Report Form Number

Patient Details
Name
Address
Age
Date of Birth
Sex
GP
Contact
Postcode

Response details
Date
Vehicle call sign
Vehicle home station
Vehicle location at time of call
Type of call
    999 + MPDS/CBD code
    GP Urgent
    Other
Times
    Call received by AS
    Time passed
    Mobile
    At scene
    At patient
    Left scene
    At Hospital
    Clear
Destination hospital
Hospital department

Incident Details (Link to AMPDS/CBD Codes where possible)
Type
    Work
    Leisure
    Home
Cardiac
    Arrest
    Pain
    Other
Respiratory
    Asthma
    Other
Neurological
    CVA
    Convulsion
Medical
    Diabetes
    Other
DSH
    Overdose
    Injury
GI
    Pain
    Acute Abdomen
    GI Bleed
Obs & Gynae
    Miscarriage
    Ectopic
    Labour
    APH
    Foetal movements
    Delivered
    PPH
Assault
    Blunt
    Penetrating
Fall
    <2m
    >2m
RTA
    Vehicle occupant
      Driver
      front/rear passenger
    Pedestrian
    Motorcycle
    Cycle
    Entrapment and duration
    Ejection
    Fatality
    seatbelt
    head restraint
    air bag
    child restraint
    crash helmet
    alcohol
Drowning
Psychiatric
Burns
    Area%
    Severity
Other
Time of incident
location of incident
history of incident

Significant Past Medical History
None
Not known
Details
    Signs & Symptoms
    Allergies
    Medication
    PMH
    Last meal
    Events prior to call
    Other
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES

Primary Survey
Airway
    Clear
    Blocked
    Aspirated
Spine
    Normal
    suspect
Breathing
    Normal
    Absent
    Abnormal
Circulation
    Radial pulse palpable
    capillary refill >2secs
AVPU

Secondary Survey
ABCD's
Summary of injuries & clinical findings
    Nausea
    buccal mucosa
    pallor
    sweating
    fitting
Picture of body outline
    closed#
    open#
    pain
    echymoses
    abrasion
    laceration
    burns
    foreign body
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES

Serial Observations
Pulse
BP
Respiratory rate
Pupil size
Pupil reaction
GCS
TRTS
Oxygen saturation
Peak flow
Blood glucose
Temperature

WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES

Cardiac Care
Witnessed arrest
    by whom
CPR/ALS prior to AS arrival
    by whom times/duration
Treatment by AS
    BLS
    ALS
Monitor
    Rhythm strip
    ECG
Initial rhythm
Defibrillation
    Manual
    AED
      Bi/Uni-Phasic
Times
    Bystander CPR
    EMS CPR
    first shock
    Cannulation
    Drugs/fluids
    Time respiration returned
    Time circulation returned
    Time CPR stopped
    Time onset of chest pain
Shocks
    Initial rhythm
    number
    size
    result (ROSC)
Other cardiac treatment

WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES

Resuscitation
Airway & Breathing
    Head/chin tilt/lift
    Jaw thrust
    Oropharyngeal airway
    Nasopharyngeal airway
    other device
    BVMR
    pocket mask
    LMA/ Combi Tube
Suction
Manual clearance
Intubation
    size
    by whom
    failed attempt
    ventilator settings
Oxygen
    flow rate
    %
Circulation
    cannulation
    size
    site
    failed attempt
    total volume given
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES

Splints
cervical collar
    size
spinal board
vacuum mattress
traction splint
vacuum splint
box splint
inflatable splint
frac straps
Sam splints
peripheral circulation in tact
RED
Other

Other procedures
cricothyrotomy
needle thoracocentesis
Intraosseous needle

Other treatment
Drugs/Fluids
time
dose
route
by whom

WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES

Condition on arrival
Working diagnosis
Second CBD/AMPDS Code defined by crew
Spontaneous respiration
spontaneous circulation
AVPU/GCS
Dead
    Recognised at scene
    by whom
    confirmed by doctor
      name
Crew signature

Hand over
to whom
time
position
signature
Disposition of property

Disclaimer
suitable wording
signature of patient/ responsible adult

Additional Information

WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES
14/06/99 SN
     
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