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\ p None B a = c @ = Z ?N*8 X" 1 Arial1 Arial1 Arial1 Arial1 Arial1 Arial1 Arial General ` cA survey = choices Q settings type name label::English(en) hint::English(en) $given_name read_only calculation text FCN **A)IDENTIFICATION PANEL [PATIENT RECORDS]**
1.Fill in the following identification patient information from the patient record form?
Form Code No: Reviewer Reviewer's Name begin_group contact Patient contacts [Phone]: integer contact1 Contact 1 contact2 Contact 2 end_group next# Next of Kin contact & relationship contacta Contact Kin Relationship FacCode Facility Code:SS- date Review Review Date: DDMMYYYY B1_1 **B) PATIENT DEMOGRAPHICS CHARACTERISTICS [PATIENT RECORDS]**
1.What is the patient Accident and Emergency code (number)? [At final Trauma Management Facility] B1_2V 2.What is the inpatient admission code (number)? [At final Trauma Management Facility] B1_3e 3.If brought by ambulance, what is the ambulance code (number)? [At final Trauma Management Facility] B1_4q 4.If brought by ambulance, what was the name of ambulance service provider [At final Trauma Management Facility] B1_5R 5.What is the ambulance registration number? [At final Trauma Management Facility] B1_6E 6.If referred from another facility, what was the referring facility? select_one b1_7 B1_7G 7.If referred from another facility, what was the triage patient status B1_7oth 7 Other specify B1_8f 8.At what time and day was the patient received in the facility? [At final Trauma Management Facility] B1_8a Date time B1_8b Time 24HR FORMAT B1_9S 9.What was the triage patient status at the A&E? [Final Trauma Management Facility] B1_9oth select_one b1_10 B1_10/ 10.What was the patient status at the admission select_multiple b1_11 B1_11- 11.Where was the patients admitted after A&E? B1_11oth6 Transfer other
B1_11oth98
Other Specify B1_12' 1 2 . W h a t i s t h e p a t i e n t s d a t e o f B i r t h ? B1_135 13.What is the age of the patient (If DOB is missing) select_one b1_14 B1_14% 14.What is the gender of the patient? B1_15K 15.What is the stated area of residence for the patient [at time of injury] B2_1b\ **Pattern of Major Injuries**
1a.When did the Injury occur? B2_1ba B2_1bb select_one b2_1bc B2_1bc Day B2_2a 2.Where did the injury occur? B2_2a_001
Specific site B2_2b County select_multiple b2_3 B2_3" 3.What is the mechanism of injury? B2_3oth 3.Other Specify select_one b2_4 B2_4 4.If RTA, what type B2_4oth 4.Other Specify select_one b2_5 B2_5<