Radio Medical Record – First contact

Name/titel: Date of birth: Sex: Nationality: Date: UTC:

John Hansen 11/02/1958 M Danish 18/09/20202245
Company: Name of the ship: Ship´s e-mail: Satellite call no.: Call sign:
ABC Shipping M/S Mayflower master@mayflower.com 12345678 ABCDE
Position: Port of destination / ETA: Nearest port / ETA: Medicine chest: Page 1 of:
S of Pearl Harbour Houston / 29th Sep - 0000Pearl Harbour / 19th Sep - 0145 UTC A - MFAG A1 6

Does the patient take any medicine? Is the patient known to suffer from any allergies?
If yes, which: 150 mg acetylsalicylic acid daily, If yes, which:

No Don´t know: No Don´t know:

Course of events – Please describe what has happened
Problem: A/E cut himself on an angle grinder on his right forearm.

Symptoms: The wound is 10 cm long and approx. 0.5 cm deep. There is no other visible damage
Bleeding has been stopped by applying compression bandage.

A: Airway
Examine Observation Action
Free airways Yes ( ) No ( ) If no: -> Jaw lifting ( ) Tongue depressor ( )

Suction Yes ( ) No ( ) - Unconscious and no breathing/ gasping breathing:

CPR has been initiated at: hours

OXYGEN GIVEN Administered oxygen: litre / min.

Back of head / back

Suspected injury: Yes ( ) No ( ) Neck collar applied: Yes ( ) No ( )

B: Breathing
Examine Observation Action
Breathing frequency and Yes ( ) No ( ) Description of breathing:
depth ( See–listen–feel )
Rapid ( ) Superficial ( ) Slow ( ) Rattling ( ) Other: Normal

Number of breaths / min.:

Saturation Yes ( ) No ( ) Saturation i %: 96

C: Circulation
Examine Observation Action
Capillary response <2 sec ( ) >2 sec( ) If more than 2 sec. IV - needle: Yes ( ) No ( )
Colour of skin Normal: Yes( ) No( ) If no, which colour: pale
Temperature and humidity Normally dry and warm If no, how does the skin feel:
of skin Yes ( ) No ( ) Moist
Pulse Pulse beat / min. Pulse beat recorded: 100 wrist ( ) neck ( )
Blood pressure Recorded blood pres­sure Systolic (high): 145 / 90 Diastolic (Low)
 Radio Medical Record – First contact
D: Disibillity
Examine Observation Action
Conscious Yes ( ) No ( ) Level of consciousness: ( ) 1. Awake, conscious and well-oriented
( ) 2. Confused, but reacts when spoken to
( ) 3. Confused, but reacts to pain stimuli
( ) 4. No reaction to pain stimuli

Cramps: Yes ( ) No ( ) Paralysis: Yes ( ) No ( )

Pupil reaction Normal: Yes( ) No( ) If yes, please describe using: +/+ (uniform contraction of both pupils)
If no, Please describe what you see:

E: Expose
Examine Observation Action
Top to toe examina­tion. Yes ( ) No ( ) If yes, please describe the symptoms/actions:
Signs of injuries/ illness There is no other visible damage
not identified under Bleeding has been stopped by applying compression bandage.
A-B-C-D
Signs of Hypothermia or Yes ( ) No ( ) If yes, please describe the symptoms/actions:
Hyperthermia
Temperature measure Yes ( ) No ( ) Temperature measured in mouth: Alternative temperature measure: Where:

Actions taken, but not described:

E.g.: The patient is still lying strapped on a spine-board:
Bleeding has been stopped by applying compression bandage.
Tetanus Vaccine is ok

Photograph attached

If relevant / possible attach photo(s).

Medicine administered
Time: Time:
Time: Time:

Name/title of the person in charge of medical care:

Anshul Sharma / Master
____________________________________________
 Radio Medical Record - Observation form
Name of patient / CPR number:

Date
18/09/2020

Time 2245

General condition (1 – 4)
2

Level of consciousness (1 – 4)
1

Oxygen litre / min.

NA

Breathing frequency / min.

20

Capillary response in sec. > 2 sec

Oxygen saturation in % 96

Pulse beats / min. 100

Blood pressure 145 / 90

Temperature ( in the mouth ) NA

Pupil reaction ( normal +/+) +/+

IV - needle inserted ( yes / no ) no

Fluid through drip, drips pr. min. no

Fluid intake NA

24 - hour urine sample NA

Dipstick NA

Blood sugar NA

Malaria test NA

Assistance for establishing the level in the above table:

General condition Level of consciousness Pupil reaction

1 = The patient is not affected
2 = The patient is somewhat affected (e.g. pains)
or the patient is a little ill
3 = The patient has pains or is ill
4 = The patient has much pain or is very ill
1 = The patient is awake, conscious and well- Pupil reaction normal at light source: plus = (+/+)
oriented
Any abnormal reaction describe:
2 = The patient is confused, but reacts when
spoken to e.g. Rigth pupil big without reaction to light
3 = The patient is confused, but reacts to pain
4 = No reaction to pain stimuli
 Radio Medical Record - continued documentation
Time Radio Medical prescription:
Mark on the picture focus of pain, injury or symptom

Back Front
 Table of fluids
Time Fluid input Time Fluid output (Evaporation: 1000 ml. / 24 hours)

Total amount intake of fluids pr. 24 hours: Total amount output of fluids pr. 24 hours:
Notice: body’s evaporation, 1000 ml extra per day, must always be added in your calculation.
In case of fever, evaporation is increased by 300 ml per degree,
the temperature rises above 37 degrees / 24 hours (see the medical guide)