Table 1 The standardised clinical set data gathered on the observational charts
Name | |
Date of birth | |
Date and time of presentation | |
Who brought the patient? | |
From where was the patient brought? | |
Substances of abuse taken | |
Time when taken | |
Quantity taken | |
What has happened? (free text) | |
Previous medical history | |
Seizures (yes/no) | |
Diabetes (yes/no) | |
Serious psychiatric disorder (yes/no) | |
Known substance use (alcohol/opioids/other/none) | |
Clinical status at presentation | |
Respiratory rate | |
Heart rate | |
Blood pressure | |
Temperature | |
Blood glucose level | |
SpO2 | |
Track marks (yes/no) | |
External signs of injury (yes/no) | |
Nystagmus (yes/no) | |
Plantar reflexes (down/inverted) | |
Pupil size (large/small/normal) | |
Other information (free text) | |
During observation time (fields provided for repeated observations) | |
Glasgow Coma Scale score | |
Pupil reaction to light (+/+) | |
Respiratory rate | |
SpO2 | |
Symmetric movement of arms and legs | |
Medication given | |
In ambulance | |
At the casualty clinic |