Pre-hospital record keeping: DipIMC practice questions

Answer: B

Spinal pain, hand or foot weakness, altered hand or foot sensation, priapism, and whether improving

NICE NG41 sets out what the pre-hospital record must contain for a person with suspected spinal injury: the <C>ABCDE findings and four spinal items — spinal pain; motor function, for example hand or foot weakness; sensory function, for example altered or absent sensation in the hands or feet; and priapism in an unconscious or exposed male. A companion recommendation adds that, if possible, the record should show whether the person's condition is improving or deteriorating on reassessment. The ASIA chart, vital capacity and ability to cough belong to the emergency department (ED): NG41 asks for the ASIA chart to be completed as soon as possible in the ED for people over 4 with suspected cord injury. The other distractors are plausible things to write down, but they are not the NG41 pre-hospital dataset: neck rotation, midline tenderness, distracting injury and intoxication belong to the assessment and clearance steps, while mechanism, scene time and device details are general record content rather than the spinal items NICE specifies. The professional duty sits alongside: HCPC standard 10 requires full, clear and accurate records for everyone a registrant cares for.

Answer: E

One member is designated to record findings and interventions as they occur

NICE NG39 recommends that one member of the trauma team is designated to record all trauma team findings and interventions as they occur — contemporaneous notes — and that the trauma team leader checks the recorded information for completeness. A pre-hospital critical care team applies the same principle by allocating a scribe. NG39 separately says the pre-hospital documentation, including the pre-alert, should be quickly available to the trauma team and placed in the patient's hospital notes, so no approach that leaves the pre-hospital phase to be reconstructed by the hospital is acceptable. Writing the record from memory after handover, splitting it across separate sheets, or relying on the crew's record or a monitor download all lose drug doses and times, physiology trends and the sequence of events. The Oxford Handbook accepts that a lone practitioner may have to write notes retrospectively after handover, but says this is no reason for inadequate or incomplete records and that missing clinical data should not be guessed or estimated; a three-person team is not in that position.