Complete Relevant Workplace Documentation, Including Incident Report Form and Follow Workplace Procedures to Report Serious Incidents to the Regulatory Authority

Record details of casualty

Documentation may include:

• Injury report forms
• Workplace documents as per organisation requirements

Documentation may include recording: time; location; description of injury; first aid management; fluid intake / output including fluid loss via blood, vomit, faeces, urine; administration of medication including time, date, person administering, dose; vital signs.

It is vital that any first aid management, which occurs in the workplace, is recorded in a Record Logbook.

The Record Logbook should include the following information:

• Name of casualty
• Witnesses
• Detailed description of incident
• Time and date
• Outcome
• Signature of those involved, and their position
• Management comment and recommendations
• Follow up

This record would be sent to management who would then be expected to read and follow up on the incident, including making recommendations to prevent or minimise the incident from occurring again. The record would be kept on the premises for future reference.

Physical condition

When you are recording the details regarding the physical condition of the casualty, you need to write objectively, not subjectively, and include observation of the facts i.e. the signs and the symptoms.

Scenario: sprained ankle

The correct way

An example of writing objectively about the casualty's physical condition is:

• At 1.10 pm 1/11/02, (casualty's name) was found by (your name) lying on the floor of the tearoom holding his left ankle. (Casualty's name) stated that he tripped over his untied shoe laces and that his left ankle was very painful. On inspection, his left ankle was swollen and slightly bruised. (Your name) called for help and (first aider's name) arrived on the scene

The incorrect way

Do not use emotive language when reporting on the casualty's physical condition.

Below is an example of how not to write:

• At 1.10 pm 1/11/02, I went to the tea room because I was hungry and I was late for my lunch break and I found (casualty's name) lying on the floor. I panicked and ran for help because I thought (casualty's name) had broken his leg. When I returned, I had calmed down and saw that his left ankle was huge. My supervisor took over the first aid management as I wasn't sure what to do

Changes in conditions

Any changes in the casualty's physical condition also need to be reported, again in an objective manner.

Scenario: asthma attack

Here is an example of documenting changes in the physical condition:

• At 11.20 am 12/5/02 (casualty's name) was having difficulty breathing, was wheezing and very distressed. She was pale and clammy. (Your name) sat her in a chair and called for help. At the same time (your name) loosened her clothing, opened the window and turned on the fan. Suddenly, (casualty's name) started turning bluish around her mouth.

Management

It is important that all management given to the casualty is fully documented.

Sprained ankle

• (Casualty's name) was helped to the closest chair, his shoe removed, left foot elevated, and an ice pack and a compression bandage were applied to the left ankle.

Asthma attack

• (Casualty's name) stated she needed her Ventolin inhaler which (first aider's name) gave to her. (Casualty's name) took four puffs of the inhaler. One minute later, she turned very blue around the mouth and collapsed. She was found to be unconscious and not breathing.

Response to management

In addition to reporting on the physical condition of the casualty and first aid management, you will also need to report on the response to the first aid management. In other words, what happened after first aid was given. Was the first aid management effective? Did the casualty recover?

We will use the two scenarios above to document the first aid management response.

Sprained ankle

• (Casualty's name)'s wife was telephoned. She arrived at the workplace at 1.55 pm with a pair of crutches to take (casualty's name) to the local doctor and to have an X-ray. (Casualty's name)'s wife was directed to keep the ice pack on for 20 minutes every two hours for the first 24 hours and for 20 minutes every four hours for the next 24 hours, as well as to keep the left foot elevated and leave the compression bandage in place. She was also asked to phone the workplace the next day to let staff know about (casualty's name)'s condition. Management has also been informed and this report filed.

Asthma attack

• (Your name) ran to call an ambulance while (first aider's name) commenced expired air resuscitation. The ambulance arrived at 11.35 am and took over the resuscitation. The ambulance crew took (casualty's name) to Accident and Emergency at St Paul's General Hospital. The family has been informed and will phone us later with an update of (casualty's name)'s condition. Management has also been informed and this report filed.

After filling out the accident/incident report, submit it to management.