Record keeping and data protection in healthcare
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A prehospital patient record (PPJ) is not just a piece of paperwork you fill out when the rush is over. It is the document that follows the patient forward into the hospital and at the same time it is your own security if a procedure later needs to be reviewed. Use this template as a fixed checklist for what the record must always contain.
§Fixed standing information.
- 01Time of alerting, departure, arrival at the scene and departure from the scene
- 02Patient's identity, or indication that the patient is unidentified
- 03Type of incident and brief description of injury site/situation
- 04Who performed the treatment (you and your partner)
§Clinical course — completed continuously
| Time point | Observation / action | Value or result |
|---|---|---|
| Consciousness level | ||
| Breathing (frequency, work) | ||
| Pulse and blood pressure | ||
| Oxygen saturation (SpO2) | ||
| Treatment given (oxygen medication bandage etc.) |
§Medicine and treatment — every time
- 01Preparation, dose, and route of administration
- 02Time of day for each given dose
- 03Power/response to treatment.
- 04Who prescribed it (own competence, or prescription from doctor — specify which)
§Handover and conclusion
End the log with a short, structured summary, preferably using the ISBAR method (Identification, Situation, Background, Analysis, Recommendation), so whoever reads the log afterwards can quickly get an overview without having to read the entire course again. Note who the patient was handed over to and on which ward.
Quick check before the journal is closed
- 01Does the number of pattern pieces match what should actually be cut (lining, inserts, pockets, etc.)?
- 02Is all cabling and installation checked against the diagram?
- 03Does it clearly indicate who the patient is handed over to?
- 04Is the language concrete and free of unclear abbreviations others might misunderstand?