ALCOHOL IN THE ED - ASSAULTS AUDIT
Family name: ______First name: ______
Case note number: CHI number: Audit no:
ÿðÿðÿðÿðÿð ÿðÿðÿðÿðÿð ððÿðÿðÿ
Alcohol in the ED - Assaults Hospital code: ÿðÿÿð Audit no: ðÿÿðÿðÿ
Postcode: ðÿðÿ ÿ Sex: ð 1 = male 2 = female Age: ðÿð
Enter the ED Date: ðð.ðð.ðð Time: ðð:ðð
Re-presentation: ð 0 = no 1 = yes Seen in Resus: ð 0 = no 1 = yes
Mode of arrival: ð 1 = Self 2 = GP 3 = SAS 4 = NHS 24 5 = Police 6 = Telemedicine 7 = Other Specify: ______
Observations: GCS ðð E ð M ð V ð Sys BP: ðÿð HR: ðÿð RR: ðÿ
Source of observations: ð 1 = PRF 2 = ED card
Nature of Assault
Components: ðð 0 = None 1 = Racial 2 = Sectarian 3 = Sexual orientation 4 = Indecent assault 5 = Not documented
Location: ð 1 = Bar/club 2 = Street 3 = Home 4 = Workplace 5 = School 6 = Other Specify: ______
Type of injury: ð 1 = Blunt 2 = Penetrating 3 = Both
Nature of injury: ðððð 1 = fracture 2 = Contusion 3 = Laceration 4 = STI 5 = Burn 6 = Internal 7 = Head Injury
Body Region: ð 1 = Head & Neck 2 = Facial 3 = Chest 4 = Abdo 5 = Extremity 6 =Multiple
Weapon used: ð 0 = No 1 = Glass 2 = Knife 3 = Gun 4 = Blunt Object 5 = Not documented Specify: ______
Was the alleged assailant known to the patient? ð 0 = no 1 = yes 2 = not known Assailant: ð 1 = Male 2 = Female
Was it: ð 1 = Partner 2 = Ex-partner 3 = Family member 4 = Acquaintance / friend 5 = Colleague 6 = Stranger 7 = Bouncer
8 = Other 9 = Group
Specify: ______
Use of Alcohol
Was alcohol a contributory factor in the patient’s presentation to the ED: ð 0 = no 1 = yes 2 = not known
Had the patient consumed alcohol in the previous 24 hours: ð 0 = no 1 = yes 2 = not known
Had the alleged assailant consumed alcohol at the time of the assault: ð 0 = no 1 = yes 2 = not known
Was a screening tool used in the ED: ð 0 = no 1 = yes 2 = not known
If yes, which: PAT ð FAST ð CAGE ð AUDIT ð
F1F
Further Management
Referred to: Speciality: ð Alcohol Liaison Nurse: ð Psychiatric Services: ð OPD: ð
0 = no 1 = yes 2 = not known 3 = service not available
Detained under Mental Health Act: ð 0 = no 1 = yes
Disposal from the ED: ðð Leave ED date: ðð.ðð.ðð Leave ED time: ðð:ðð
1 = Home / 6 = Ortho / 11 = Neurosurgery / 16 = Specialist NHS treatment2 = SSW / 7 = GI / 12 = Irregular discharge / 17 = Community non-NHS counselling service
3 = Assessment/CDU / 8 = ICU / 13 = Police
4 = Medical / 9 = HDU / 14 = Mortuary
5 = Surgical / 10 = Maxillo-facial / 15 = Psychiatric Unit
Are alcohol related problems documented in the patient’s PMH? ð 0 = no 1 = yes
Admitted because of intoxication alone: ð 0 = no 1 = yes
If yes, length of stay: ð 1 = <8hrs 2 = 8 - 12hrs 3 = 12 - 24hrs 4 = >24hrs
Is there documented evidence of abuse to staff in the ED: verbal: ð physical: ð 0 = No 1 = yes
Discharge from Ward Date: ðð.ðð.ðð Total in-patient days: ððð
Local Research: ðððð ðððð ðððð ðððð