Documentation

Abstract

This chapter focuses on documentation. Documentation of the casualties is vital. Any documentation should incorporate simplicity of design, accuracy in use, and speed in deployment. Many accident and emergency departments use a pro forma in their routine everyday work, to document the details of the history and examination of patients with major injuries. The scope and detail of the disaster manual should be such that it covers the sudden influx of casualties to the hospital and also internal disasters, such as fire, explosion, bomb threat, and an evacuation procedure. Normal hospital documentation should be used wherever possible, and be readily available. The request forms for blood grouping and cross matching should give an indication of the urgency of the blood required. The chapter illustrates a major injury pro forma incorporating a disaster identification tag and an initial triage category.