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Documentation of case information

Clinical documentation preserves the information, source, priority, confirmed outcome, and signer at the point of decision. Each document has a defined audience and later notes do not silently rewrite the signed record.

Documentation of case information
Care Record

01

Care Record

For the clinician and the clinical record. Relationship, safety notes, concern, colour, observations, red flags, the conversation, the outcome, and the signer. Profession and organization are printed on the signature.

Emergency Handover

02

Emergency Handover

For the receiving emergency department. Situation, background, assessment, recommendation. Age, allergies, confirmed earlier contacts, the caller’s own words beside the flags, and where the person is. Not the full conversation. A red handover waits for a senior signature.

Crew Brief

03

Crew Brief

For the ambulance crew. Where to go, the colour, the concern, the callback number, and the contact reference. Short enough to read on the way. The service does not dial the emergency number itself.

Patient Summary

04

Patient Summary

For the person, and anyone they choose to show it to. The next step, the emergency number, the warning signs, and what they answered. It does not wait for the senior signature. They can hold it up for the next clinician.