Medical Reports & Forms

All medical reports and their disclosure are governed by applicable Privacy Laws. Ensure compliance when accessing, handling, or sharing protected health information (PHI).

There is an MDT Report Template to guide you writing reports. The below information is for additional immersion.

Types of Medical Reports

General Medical Records

These are the most common reports created for patient care and typically include:

  • Patient Name
  • Presenting Condition
  • Medical Evaluation
  • Procedures Performed
  • Post-Op / Discharge Instructions
  • ICU Follow-Up Notes (if admitted)
  • Time of Death (if applicable)

In Case of Emergency (ICE) Report

ICE reports are used in critical situations to retrieve essential patient information and contact designated individuals. ICE contacts may be granted access to scene-specific medical details depending on the situation.

Common fields include:

  • Patient Name
  • Date of Birth
  • Height & Weight
  • Emergency Contacts (Personal & Professional)
  • Medical History / Diagnoses
  • Family Medical History
  • Allergies
  • Blood Type
  • Donor Status

Mental Health Records

Filed when a patient presents with or is diagnosed with a mental health condition. These reports should be handled with extra discretion.

Details include:

  • Patient Name
  • Diagnosis
  • Prescribed Medications
  • Work or Activity Clearance (if applicable)
  • Relevant Linked Medical Reports

Physical Exam Records

Often required for employment or governmental clearance, these comprehensive medical exams typically document:

  • ICE Report Data
  • Vision and Hearing Tests
  • Cardiopulmonary Exam (Heart & Lungs)
  • Blood Panel Results
  • Drug Screening
  • Physical Fitness Assessment

Staff Patient Lists

For specialised staff managing ongoing or high-volume patient cases. Maintaining this list is encouraged for continuity of care.

Recommended fields:

  • Staff Member’s Name
  • Current Active Patients + Contact Info + Report Links
  • Waiting List Patients + Contact Info
  • Archived Patients (previously under care)

Autopsy Records

Created when a patient has died and an autopsy is performed. These are official documents used for medical and legal purposes.

Typical contents:

  • Patient Name
  • Summary of Fatal Injuries
  • Personal Effects Collected
  • Certified Death Certificate

Medical Record Access Log

Used to track external or law enforcement access to medical records. Helps support IC audit trails and RP transparency.

Track the following:

  • Name of Report Accessed
  • Requestor’s Name
  • Requesting Agency or Department
  • Linked Police/DOJ Case or Incident Number
  • Date of Access
  • Medical Staff Member Who Accessed

Medical Forms

EMS Medication Prescription Form

This EMS Medication Prescription form must be completed by an authorised prescriber before issuing any medication. A detailed report is required prior to prescription issuance. The form includes essential patient and medication details, dosage instructions, and prescribing authority information. It also outlines repeat limits and safety intervals to ensure responsible use and prevent misuse.

PLEASE NOTE: A REPORT IS REQUIRED TO ISSUE A PRESCRIPTION

  • Title: PHMC - EMS Medication prescription
  • Prescribing Body: [rank+name]
  • Patient name: [name]
  • Medication being Issued: [medication_type]
  • Dosage: [the amount and how often med is to be used]
  • Reason for issuing: [very short description incl. report ID]
  • Date of Prescription: [XX/XX/XX]
  • Repeat: [the amount of times the patient can request this medication before needing another review, make sure to include a minimum time frame i.e 7 days to prevent addiction/overdosing ]
  • Expiry Date: [When the prescription is no longer valid]
  • Prescribing Body Signature: [Your signature]