Pre-reading

Recording and Reporting

It is necessary to record and report details of any first aid incident. As soon as possible the first aider should collect, collate and document as much relevant information about the casualty(s) as possible and should include:

• • a detailed history of the incident, (what happened, when, how and why)
  • a description of the first aid management of injury/illness, including the use of any form of medication and the giving of food/fluid
  • the time, date and location of incident
  • people involved in the incident, include your name and contact details.

Follow general documentation principles: Write clearly in pen

• • Use simple, non-jargonistic terms
  • Do not obliterate any words or sentences, if a mistake is made strike a single line through the error, initial the mistake and continue
  • Sign, date and witness the report
  • Always maintain confidentiality and provide reports to health care professionals, on a need-to-know basis.