= YES = NO ✓ ✗
(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
EM/ORTHO/RAD 10/2017! 1
Date: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMO
HISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINT
THJR dislocation:THJR dislocation: Left Right Left RightMechanism of dislocation:Mechanism of dislocation:
Fasting status:Fasting status:
RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY Nil relevant
CVS: IHD:
AF / PAF → Anti-coagulated: AF / PAF → Anti-coagulated: Yes No
Resp: COPD / Asthma COPD / Asthma
Anaest: Known difficult airway: Known difficult airway:
Known anaesthetic concerns: Known anaesthetic concerns: Known anaesthetic concerns:
Ortho: THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________
Previous dislocations: Previous dislocations:
Reduced in ED: Drugs used: Reduced in ED: Drugs used: Reduced in ED: Drugs used: Reduced in ED: Drugs used:
Reduced in theatre: Reduced in theatre: Reduced in theatre: Reduced in theatre:
RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES Nil regular medicines Nil regular medicines
See electronic medical record for full list See electronic medical record for full list See electronic medical record for full list See electronic medical record for full list
Nil known allergies Nil known allergies ALLERGIES:ALLERGIES:
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TOTAL HIP JOINT REPLACEMENT DISLOCATION
7.7.
204
B
7.7.
057
A
= YES = NO ✓ ✗
(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
EM/ORTHO/RAD 10/2017! 2
EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION
AIRWAY Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?
No Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form
CVS Warm and well perfused Warm and well perfused
Cap refill Normal
Pulses Normal
Respiratory
Breathing work Normal
Breath sounds Vesicular
Added sounds No Yes:
VITAL SIGNS
Within normal limits
VITAL SIGNS
Within normal limits
BP ______________ mmHgBP ______________ mmHg Resp Rate _________ minResp Rate _________ min Pain score _____ /10Pain score _____ /10VITAL SIGNS
Within normal limits
VITAL SIGNS
Within normal limitsPulse ______________ bpmPulse ______________ bpm SPO2 ______________ %SPO2 ______________ %
VITAL SIGNS
Within normal limits
VITAL SIGNS
Within normal limitsTemp ______________ ℃Temp ______________ ℃ Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min
General NOT distressed NOT distressed
Pain None Mild Moderate Severe
FUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HX
Living situation: alone Mobility: independent Activities of daily living: independent with family walking stick needs some help e.g. cleaning rest home walking frame significant help e.g. dressing private hospital wheelchair needs help eating other: immobile completely dependent
Occupation
Supports
Access at home steps:
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(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
EM/ORTHO/RAD 10/2017! 3
MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER
No other injuries No other injuries
D - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tear
NEUROVASCULAR STATUS NEUROVASCULAR STATUS Normal Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document
RADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGY
THJR Dislocation: Left Right Not dislocated
No fractures seen Fracture:
Post reduction: Reduced Not reduced
No fractures seen Fracture:
Films reviewed by Dr ________________________________Films reviewed by Dr ________________________________Films reviewed by Dr ________________________________ EM Specialist SMO Reg
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RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant N/A N/AHAEMATOLOGYHAEMATOLOGY BIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRY URINE MSU / CSUURINE MSU / CSUHb Na+ CRP WCCWCC K+ RCCPL Gluc NitratesINR Creat Leuc est
Epi’sBacteria
ECGECGECGECGECGECGECG N/A
Rate: NSR
Description:Description:
= YES = NO ✓ ✗
(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
EM/ORTHO/RAD 10/2017! 4
CLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANTHJR Dislocation: Left Right No dislocation No dislocationReduction in ED: Successful Not successful Not attempted Not attemptedOther problems:
FURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONS
Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway documentZimmer splint: No Yes Decision guide page 4 Best Care Bundle No Yes Decision guide page 4 Best Care Bundle No Yes Decision guide page 4 Best Care Bundle No Yes Decision guide page 4 Best Care Bundle Allied health:
Please only request Allied Health review if
concern re mobility or patient home situation
Inpatient Physiotherapy Inpatient Physiotherapy NSH 931905 WTH 021 854 358 / 931659
Mon-Fri 8am-3pm Sat/Sun 8am-1pmMon-Fri 8am-4pm
Allied health:Please only request
Allied Health review if concern re mobility or patient home situation Discharge coordinator Discharge coordinator NSH 3861
WTH 021 911 796Mon-Sun 8am-3pm Mon-Sat 7am-5pm
Analgesia: REGULAR analgesia charted REGULAR analgesia charted Current pain score: _____ / 10Current pain score: _____ / 10
Education: Patient advice sheet and hip precautions explained. See patient advice sheet. Patient advice sheet and hip precautions explained. See patient advice sheet. Patient advice sheet and hip precautions explained. See patient advice sheet. Patient advice sheet and hip precautions explained. See patient advice sheet.
Discharge criteria & checklist page 4 Best Care BundleDischarge criteria & checklist page 4 Best Care BundleDischarge criteria & checklist page 4 Best Care Bundle
Discharge checklist Mobilising well & independently Mobilising well & independently Procedural drugs and dosages noted in EDS Procedural drugs and dosages noted in EDS
Hip precautions reinforced 6/52 Hip precautions reinforced 6/52 Patient information sheet provided Patient information sheet provided
Follow up Orthopaedic clinic referral done Orthopaedic clinic referral done Back to original surgeon or own surgeon if done in privateBack to original surgeon or own surgeon if done in private
Inpatient referral Discussed with Dr: ______________________ Time: __________ Discussed with Dr: ______________________ Time: __________ Discussed with Dr: ______________________ Time: __________ Discussed with Dr: ______________________ Time: __________ Adequate analgesia charted Adequate analgesia charted NBM / chart IV maintenance fluids NBM / chart IV maintenance fluids
Waitakere patients: transfer to NSH by ambulance with transit care Waitakere patients: transfer to NSH by ambulance with transit care Waitakere patients: transfer to NSH by ambulance with transit care Waitakere patients: transfer to NSH by ambulance with transit care
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Clinician Name: Designation: Sign: Contact details: _________
For junior staff: Discussed with Reviewed by SMO Dr : _____________________ Sign: __________