Maintain Confidentiality of Records and Information in Line with Statutory and/or Organisational Policies
When preparing a report some general guidelines should be followed:
- Use black or blue ink only
- Any corrections should be crossed out with a single line and initialled. Do not use correction fluid to correct any mistakes
- Sign and date the record
- The information should be kept confidential and should only be accessed by authorised people. Who is authorised to access the records varies in different State or Territories.
- In a workplace incident, a copy should go to authorised employer representatives for auditing and OHS/WHS monitoring purposes
Documenting your treatment
The accurate recording of injury/illness is also of great assistance to any medical personnel who take over your casualty's treatment, such as ambulance officers. The format that is used to report injury and illness varies from workplace to workplace and from State to State due to different policy requirements or legislation.
The information which should be contained in an injury/illness report is:
- The date and time of incident
- Brief personal details (name, address, date of birth)
- History of the illness/injury
- Observations (signs, symptoms and vital signs)
- The first aider's assessment of the injury illness
- Date
- Signature of first aider
- The date of report
- Print name and title of first aider
Copies of reports should be given to:
- The person taking over care
- The casualty
The first aider keeps a copy as a record, which is to be kept secure. A copy of the report should be sent with the casualty to the hospital or medical facility.
A sample injury/illness report form on the next page shows the essential amount of information required.
When offering first aid care to any casualty it is important that you can keep any information that you gain confidential. Information about the nature of the accident or the condition of the casualty should only be conveyed to Emergency Services personnel and/or the workplace supervisor, if appropriate.
