Report formats: MIST, IMISTA, ETHANE, SOAP

Jackwabbit

交更 Handover formats: MIVT = MIST (also see below)

IMISTA: Introductory information (pt's name, age, gender), Main presenting problem / MOI, Injuries or Illness, Signs and Symptoms (including vital signs), Treatment provided and response to treatment, Any other relevant information (past Hx, allergies, medications...).     Source: Remote Area Nurses Emergency Guidelines 2012-2013, pg 144:
http://www.ambulance.vic.gov.au/Media/docs/RAN-Guidelines-81ae0568-940d-404d-acd9-aae84eeeea0c-1.PDF

IMIST-AMBO: Identification, Mechanism/Medical complaint, Injuries/Information relative to the complaint, Signs, Treatment & Trends, Allergies, Medication, Background history, Other information.   Source: NSW Ambulance/Emergency Department Handover Project Report, 2010:
http://centreforhealthcom.org/wp-content/uploads/2011/05/Amb-ED_Report_Online.pdf

Jackwabbit

上述 Remote Area Nurses Emergency Guidelines 2012-2013, pg 140:
http://www.ambulance.vic.gov.au/Media/docs/RAN-Guidelines-81ae0568-940d-404d-acd9-aae84eeeea0c-1.PDF
有個用 ETHANE 寫成的 sitrep ( 情況報告, situation report): Exact location, Type of incident, Hazards, Access / egress, Number of victims, Emergency resourses at scene / required.
fb 急救醫療交流區 有個 card photo:
http://www.facebook.com/groups/176334495755335/#!/photo.php?fbid=10151452236008040&set=o.176334495755335&type=1&theater

Jackwabbit

Jackwabbit 發表於 2013-4-27 15:26
上述 Remote Area Nurses Emergency Guidelines 2012-2013, pg 140:
http://www.ambulance.vic.gov.au/Medi ...

Video on IMIST-AMBO:
http://www.archi.net.au/multimedia/e-library/quality/clinical-handover/imist-ambo/imist-ambo1.html?KeepThis=true&TB_iframe=true&height=525&width=600
Posters on IMIST-AMBO:
https://secure.tcc.co.nz/ei/images/GFS13/IMISTAMBO_Handover_Protocol.pdf
http://www.archi.net.au/documents/resources/qs/clinical/clinical-handover/amb-ed/imist-ambo-poster.pdf

Make sure you pay attention during this "Hands-off Eyes-on Ears-open" + Any questions? period !!

DeMIST PAD. The art of the EMS Handover (Wylie, May 2015): http://www.badem.co.za/the-art-of-the-ems-handover-2/

An example of what NOT to do is here (time 0:25-0.55) ...
http://www.youtube.com/watch?v=598GAzWgfCA

Jackwabbit

== 淺談 SOAP notes == ( http://goo.gl/rVnZoc )
SOAP notes 是北美醫療界用來計劃處理傷患的一種 problem-oriented 病歷格式，也是外國野外急救 (e.g. WMA, WMI, SOLO... ) 慣用的推理 / 分析程序和合法的患者記錄。但是香港醫學界不用這個格式，所以在香港只有 WMAI ( 即 WMA, http://wildmed.cn/ ) 的課程有教 SOAP notes。

除了一般的患者個人資料 (姓名、年齡、性別...)，野外急救用的 SOAP notes 通常分為六個段落 ( 見參考 ):
1. Scene / Story 現場資料 / 事發描述: 活動性質、地形、天氣、事發原因 / 經過...

2. S: Subjective 患者提供的主觀資料*: MOI、主要不適 / 主訴、病狀、SAMPLE 病歷...

3. O: Objective 急救員找到 / 量度的客觀資料*: 全身檢查、維生指數...

4. A: Assessment 跟據上列資料的傷勢評估: 從嚴重至輕微的傷勢，列出一個傷患清單 ( problem list ) ...

5. A': Anticipated problem 預期難題: 在清單的每一項列出可能惡化的後果...

6. P: Plan 處理治療方案: 針對清單的每一項 A 和 A'，計劃出處治方法；包括傷勢處理，求救 / 撤離，預防惡化的措施 ，和天氣變化的對策...

在執行這個計劃時 ( implementation )，通常先處理比較嚴重的傷勢。但 SOAP notes 並非是一次性的程序，急救員必需持續評估處治效果 ( evaluation )，如有需要便要修訂計劃了 ( revision )。

下一次會講講上文的 Anticipated problem ( A' ) 預期難題。

== SOAP notes 參考 ==
http://www.wildmed.com/…/20…/10/soapnotepagefrontandback.pdf
http://outlands.chirurgeonguild.org/docu…/ChirurgeonSOAP.pdf
https://www.nols.edu/nolspro/pdf/wmi_soap_note.pdf
http://www.wildmedcenter.com/uploads/…/2/5982510/newsoap.pdf
http://www.redcross.ca/…/Wo…/Online-Tools/SOAP-Note-2013.pdf
WMI notes, Verbal SOAP Report https://www.facebook.com/notes/nols-wilderness-medicine-institute/verbal-soap-report-headlines/10151324189961331
iOS/Android app: http://rendezvous.nols.edu/content/view/2838/964/
Report format: MIST... http://www.hkcvst.org/forum/forum.php…
Google images " wilderness SOAP notes ".
* 「野外急救字母湯」http://www.hkcvst.org/forum/forum.php…

插圖: 來自互聯網資料。