= YES = NO ✓ ✗

(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

EM/ORTHO/RAD 10/2017! 1

Date: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMO

HISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINTHISTORY AND PRESENTING COMPLAINT

THJR dislocation:THJR dislocation: Left Right Left RightMechanism of dislocation:Mechanism of dislocation:

Fasting status:Fasting status:

RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY RELEVANT PREVIOUS MEDICAL HISTORY Nil relevant

CVS: IHD:

AF / PAF → Anti-coagulated: AF / PAF → Anti-coagulated: Yes No

Resp: COPD / Asthma COPD / Asthma

Anaest: Known difficult airway: Known difficult airway:

Known anaesthetic concerns: Known anaesthetic concerns: Known anaesthetic concerns:

Ortho: THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________THJR details if available: Surgeon: _________________ Date:_____________ Done at: ________________

Previous dislocations: Previous dislocations:

Reduced in ED: Drugs used: Reduced in ED: Drugs used: Reduced in ED: Drugs used: Reduced in ED: Drugs used:

Reduced in theatre: Reduced in theatre: Reduced in theatre: Reduced in theatre:

RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES Nil regular medicines Nil regular medicines

See electronic medical record for full list See electronic medical record for full list See electronic medical record for full list See electronic medical record for full list

Nil known allergies Nil known allergies ALLERGIES:ALLERGIES:

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TOTAL HIP JOINT REPLACEMENT DISLOCATION

7.7.

204

B

7.7.

057

A

= YES = NO ✓ ✗

(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

EM/ORTHO/RAD 10/2017! 2

EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION EXAMINATION

AIRWAY Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?Features suggesting difficult airway?

No Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form Yes: document these on the procedural sedation form

CVS Warm and well perfused Warm and well perfused

Cap refill Normal

Pulses Normal

Respiratory

Breathing work Normal

Breath sounds Vesicular

Added sounds No Yes:

VITAL SIGNS

Within normal limits

VITAL SIGNS

Within normal limits

BP ______________ mmHgBP ______________ mmHg Resp Rate _________ minResp Rate _________ min Pain score _____ /10Pain score _____ /10VITAL SIGNS

Within normal limits

VITAL SIGNS

Within normal limitsPulse ______________ bpmPulse ______________ bpm SPO2 ______________ %SPO2 ______________ %

VITAL SIGNS

Within normal limits

VITAL SIGNS

Within normal limitsTemp ______________ ℃Temp ______________ ℃ Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min

General NOT distressed NOT distressed

Pain None Mild Moderate Severe

FUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HXFUNCTIONAL AND SOCIAL HX

Living situation: alone Mobility: independent Activities of daily living: independent with family walking stick needs some help e.g. cleaning rest home walking frame significant help e.g. dressing private hospital wheelchair needs help eating other: immobile completely dependent

Occupation

Supports

Access at home steps:

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(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

EM/ORTHO/RAD 10/2017! 3

MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER MUSCULOSKELETAL / OTHER

No other injuries No other injuries

D - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tearD - Dislocation # - Fracture C - Contusion A - Abrasion L - Laceration P - Pain S - Skin tear

NEUROVASCULAR STATUS NEUROVASCULAR STATUS Normal Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document Compromised Documented on page 1 of Pathway Document

RADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGY

THJR Dislocation: Left Right Not dislocated

No fractures seen Fracture:

Post reduction: Reduced Not reduced

No fractures seen Fracture:

Films reviewed by Dr ________________________________Films reviewed by Dr ________________________________Films reviewed by Dr ________________________________ EM Specialist SMO Reg

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RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant RESULTS i f re levant N/A N/AHAEMATOLOGYHAEMATOLOGY BIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRY URINE MSU / CSUURINE MSU / CSUHb Na+ CRP WCCWCC K+ RCCPL Gluc NitratesINR Creat Leuc est

Epi’sBacteria

ECGECGECGECGECGECGECG N/A

Rate: NSR

Description:Description:

= YES = NO ✓ ✗

(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

EM/ORTHO/RAD 10/2017! 4

CLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANCLINICAL IMPRESSION / DIAGNOSIS / PLANTHJR Dislocation: Left Right No dislocation No dislocationReduction in ED: Successful Not successful Not attempted Not attemptedOther problems:

FURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONSFURTHER MANAGEMENT / NURSING INSTRUCTIONS

Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway document Procedure documented on page 2 of Best Care Bundle pathway documentZimmer splint: No Yes Decision guide page 4 Best Care Bundle No Yes Decision guide page 4 Best Care Bundle No Yes Decision guide page 4 Best Care Bundle No Yes Decision guide page 4 Best Care Bundle Allied health:

Please only request Allied Health review if

concern re mobility or patient home situation

Inpatient Physiotherapy Inpatient Physiotherapy NSH 931905 WTH 021 854 358 / 931659

Mon-Fri 8am-3pm Sat/Sun 8am-1pmMon-Fri 8am-4pm

Allied health:Please only request

Allied Health review if concern re mobility or patient home situation Discharge coordinator Discharge coordinator NSH 3861

WTH 021 911 796Mon-Sun 8am-3pm Mon-Sat 7am-5pm

Analgesia: REGULAR analgesia charted REGULAR analgesia charted Current pain score: _____ / 10Current pain score: _____ / 10

Education: Patient advice sheet and hip precautions explained. See patient advice sheet. Patient advice sheet and hip precautions explained. See patient advice sheet. Patient advice sheet and hip precautions explained. See patient advice sheet. Patient advice sheet and hip precautions explained. See patient advice sheet.

Discharge criteria & checklist page 4 Best Care BundleDischarge criteria & checklist page 4 Best Care BundleDischarge criteria & checklist page 4 Best Care Bundle

Discharge checklist Mobilising well & independently Mobilising well & independently Procedural drugs and dosages noted in EDS Procedural drugs and dosages noted in EDS

Hip precautions reinforced 6/52 Hip precautions reinforced 6/52 Patient information sheet provided Patient information sheet provided

Follow up Orthopaedic clinic referral done Orthopaedic clinic referral done Back to original surgeon or own surgeon if done in privateBack to original surgeon or own surgeon if done in private

Inpatient referral Discussed with Dr: ______________________ Time: __________ Discussed with Dr: ______________________ Time: __________ Discussed with Dr: ______________________ Time: __________ Discussed with Dr: ______________________ Time: __________ Adequate analgesia charted Adequate analgesia charted NBM / chart IV maintenance fluids NBM / chart IV maintenance fluids

Waitakere patients: transfer to NSH by ambulance with transit care Waitakere patients: transfer to NSH by ambulance with transit care Waitakere patients: transfer to NSH by ambulance with transit care Waitakere patients: transfer to NSH by ambulance with transit care

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Clinician Name: Designation: Sign: Contact details: _________

For junior staff: Discussed with Reviewed by SMO Dr : _____________________ Sign: __________