Patient Information Patient Information Name Name NHS and hospital numbers NHS and hospital numbers Date of birth Date of birth Address Address Contact telephone number Contact telephone number GP details GP details Next of kin details Parent/Guardian details History of Present Condition History of Present Condition Cause of burn injury (Flame, scald, chemical etc.) Cause of burn injury (flame, scald, chemical etc.) Location of where incident occurred (home, work, Location of incident occurred (home, work, indoors, inside car, outdoors etc.) indoors, inside car, outdoors etc.) Nature of the incident (accidental, suspected non Nature of the incident (accidental, suspected non accidental, deliberate self-harm, assault) accidental, deliberate self-harm, assault) Date and time of burn Date and time of burn Date and time of admission to burn service Date and time of admission to burn service Exposure to smoke or other respiratory irritants Exposure to smoke or other respiratory irritants Additional Injuries Additional Injuries %TBSA, distribution, depth (to include body diagram) %TBSA, distribution, depth (to include body diagram) Treatment at scene/first aid given Treatment at scene/first aid given Treatment to date and details of surgical Treatment to date and details of surgical interventions interventions Current medication Current medication Past Medical History Past Medical History Include all Past Medical History Include all Past Medical History Any Psychiatric History Any Psychiatric History Any Learning Disability Any Learning Disability Cognition pre-admission Developmental stage Level of physical function prior to admission Drug history pre-admission Drug history pre-admission Allergies Allergies Social History Social History Hand dominance Hand dominance Smoking history Patients accommodation detail: who they live with, Alcohol history type of dwelling Recreational drug history Pre-burn social situation. Patients accommodation details: who they live with, Pre -burn developmental stage type of dwelling Schooling Pre-burn of support from family, friends, carers. Hobbies Pre-burn level of mobility, use of walking aid Language Occupation Religion Hobbies Previous community input/ other agencies Language Substance abuse, smoking, alcohol
Patient Information Name NHS and hospital numbers Date of birth Address Contact telephone number GP details Next of kin details Patient Information Name NHS and hospital numbers Date of birth Address Contact telephone number GP details Parent/Guardian details History of Present Condition Cause of burn injury (Flame, scald, chemical etc.) Location of where incident occurred (home, work, indoors, inside car, outdoors etc.) Nature of the incident (accidental, suspected non accidental, deliberate self-harm, assault) Date and time of burn Date and time of admission to burn service Exposure to smoke or other respiratory irritants Additional Injuries %TBSA, distribution, depth (to include body diagram) Treatment at scene/first aid given Treatment to date and details of surgical interventions Current medication History of Present Condition Cause of burn injury (flame, scald, chemical etc.) Location of incident occurred (home, work, indoors, inside car, outdoors etc.) Nature of the incident (accidental, suspected non accidental, deliberate self-harm, assault) Date and time of burn Date and time of admission to burn service Exposure to smoke or other respiratory irritants Additional Injuries %TBSA, distribution, depth (to include body diagram) Treatment at scene/first aid given Treatment to date and details of surgical interventions Current medication Past Medical History Include all Past Medical History Any Psychiatric History Any Learning Disability Cognition pre-admission Level of physical function prior to admission Drug history pre-admission Allergies Past Medical History Include all Past Medical History Any Psychiatric History Any Learning Disability Developmental stage Drug history pre-admission Allergies Social History Hand dominance Smoking history Alcohol history Recreational drug history Patients accommodation details: who they live with, type of dwelling Pre-burn of support from family, friends, carers. Pre-burn level of mobility, use of walking aid Occupation Hobbies Language Social History Hand dominance Patients accommodation detail: who they live with, type of dwelling Pre-burn social situation. Pre -burn developmental stage Schooling Hobbies Language Religion Previous community input/ other agencies Substance abuse, smoking, alcohol
Therapy-Standards-Final-version-May2017.docx