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Section 1

Patient Assessment
and Transport
Patient assessment and transport

Patient presentation - (adult or child)


Primary survey
Presenting problem Commence
Yes DRABC
Why has the person presented?
Is the persons health status immediately compromised? resuscitation
No
Record emergency
Secondary survey patient history
Non-urgent presentation
Consult MO at any time. MO refer to senior MO

Determine signs, symptoms, lengths of probem? Once patient


Always ask about fever, pain, shortness of breath, stabilised complete
diarrhoea or weight loss. patient history

Determine type of history collection required?


Complete: comprehensive history of past and present health status. Re-
quired on initial visit and routinely updated as current reÀection of health
history.
Episodic: history speci¿c to current presenting concern
Interval / follow-up: history builds on preceeding visit.

Be conscious of visual or hearing impairment,


cultural identity and language spoken.

Content of history should include:


• medical, surgical history
• family, social history
• injuries, mental health history
• cultural history
• medication and immunisation history

Perform standard clinical observations


T, P, R, BP for each patient who presents for acute care
SpO2 saturation, BGL and urinalysis, if indicated
other tests as required i.e. ECG, spirometry

Body measurements
Ht, Wt, BMI, Waist circ

Perform physical examination


general appearance, skin, respiratory, nervous,
cardiovascular, gastrointestinal, ENT, eyes,

Clinical management
as set out in CCG / HMP

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Patient presentation (adult or child)


When a patient presents for health care the clinician is required to gather an orderly
collection of information to identify the patient’s health status. This information forms the
basis of patient assessment and is gained through:
• Taking a patient history
• Performing clinical observations
• Performing a physical examination
• Use of diagnostic and pathology services
• Collaboration with other members of the team

It is a requirement that all clinicians document their findings in a clear and concise way.
Quality professional documentation is the cornerstone of effective communication [1].
This section is set out to assist with documentation. It is recommended that clinicians
document the page number of HMP/CCG referred to.

Presenting concern/s
The first priority is to assess whether the person is:
• seriously ill and needs immediate management or,
• is a non urgent presentation, and there is time for a complete patient history and
health education to occur
Where possible use a private setting for the patient interview.
Use open ended questions to begin with to provide general rather than more focused
information. For example, “how do you usually deal with an asthma attack?” [2].
Closed questions can be used to focus the interview, pinpoint specific areas of concern
and gain information quickly and efficiently. For example, “has this type of allergic
reaction happened before?” [2].

Commence by introducing yourself and;


1. Asking the person what brought them to the facility / clinic today? The person may
be presenting at the invitation of a health professional.
2. Ask about the length of time the patient has had the illness / symptoms / problem and
the exact details of the signs and / or symptoms. For each of these ask: [2]
• Have they had this before? If so when and what happened?
• Location of problem / symptom – original site of presenting concern, where does
it hurt? point to the area
• Radiation – does it spread from the original site? If so where
• Quality – ask the patient to describe the way it feels to them? sharp, stabbing,
burning (use patients own words)
• Quantity – is it mild, moderate or severe? can use a pain score 0-10
• Associated manifestations – are there any signs or symptoms associated with
the presenting concern? e.g. nausea and vomiting, photophobia and headache.
Document relevant negative symptoms that are not present
• Aggravating factors – what things make the problem worse?
• Alleviating factors – what makes it better? sleeping, lying down, taking
medication?
• Setting – what were you doing when it started? where you at home? At work?
• Timing – when did it start? onset? duration and frequency

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• Meaning and impact – what does this problem mean to the patient and what
impact does it have on their life? e.g. relative may have died at a young age
having experienced a similar problem or the person may have withdrawn from
social contact
Always ask the patient specifically if they have
• Fever?
• Pain?
• Shortness of breath?
• Diarrhoea?
• Weight loss?

Patient history (adult or child)


There are four types of history taking [2]
1. Complete patient history – comprehensive history of the patients past and present
health status. Usually done at initial visit in a non-emergency situation
2. Episodic history – is shorter and specific to the patients current presenting concern
3. Interval or follow-up history – builds on a preceding visit. It documents the follow-
up required from the prior visit
4. Emergency patient history – only information required immediately to treat the life
threatening condition is gathered from patient or witnesses. Once this has past a
more comprehensive history may be taken once the patient has stabilised

This section outlines what is required for a complete patient history. The history may be
given by the patient, parent or carer in the case of a child, or legal guardian where
appointed. Consider that the patient may be visually or hearing impaired or may not
speak English. In Aboriginal and/or Torres Strait Islander communities Health Workers
will be the cultural and linguistic interpreters.
Consent is always required. The circumstances of the presentation will determine the
extent of patient history taken.

Demographic Name, address, date of birth, gender, alias, occupation, next of kin, emergency
information contact details, Medicare number, ethnic status
Medical history Have you had any illnesses / sickness in the past?
Do you have diabetes? high blood pressure? high cholesterol?
Any big worry problems? depression?
Have you ever had chest pain? heart attack? epilepsy? asthma?
For detail of special medical history such as obstetric, sexual health see related
section
Surgical history Have you had any operations? Do you know what it was for? Were there any
complications? When and where did you have the operation?

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Medication • Is the patient on any medication? (regular; occasional; prescription, non-
history prescription, complementary, or bush medicine)
• For each medicine the patient is taking, the following details are important:
− the generic name, strength and form (often patients are unable to recall or
are unaware of the full details, in which case ask the patient what they are
taking the medicine for, ask if they have their medicines with them as these
details can be obtained from the containers)
− dose and frequency
− duration of therapy, i.e. when therapy started
− are they taken as prescribed? (does the patient have difficulty
remembering or do they miss taking their pills for any reason? Remember
that non-adherence may be the reason why the patient appears to be not
responding to prescribed medication.)
− ask the patient to demonstrate use of puffers, or describe how they use eye
drops, or ear drops for example
• Patients often don’t mention medicines they think are not relevant. Therefore
using a checklist to prompt specific questions e.g. asking females whether
they are on the oral contraceptive pill, will assist in obtaining a comprehensive
medication history. See Appendix 1 Medication History Checklist
• Document medications on Medication Action Plan form
• Ask the patient if they have recently ceased or changed any of their
medications?
• Ask the patient if there is any medication they have tried for their illness which
has not worked
• It may be necessary to contact the referring facility, other primary health care
facilities, guardian or other health care providers to confirm or obtain the
medication information required
Medication allergies / adverse drug reactions (ADR)
• Try to be specific. Find out the name of drug/substance, type of reaction
suffered and its severity e.g. rash, nausea, swelling of the lips, tongue or
breathing difficulties and date that reaction occurred or approximate
timeframe e.g. “20 years ago”. Document this information on the adverse drug
reaction (ADR) section of the medication chart according to the Statewide
Medication Chart Guidelines and Non-inpatient rural and remote medication
chart guidelines. Also attach an “adverse drug reaction” sticker to medication
chart
• All Queensland Health non-inpatient facilities (and facilities discharging
patients to non-inpatient facilities, who document medication for supply on
discharge) are required to use the Non-inpatient rural and remote medication
chart and the Non-inpatient rural and remote Warfarin medication chart
• See Appendix 1 Mediation History Checklist
• Medication Services Queensland for Medication Action Plan training and
competency on Medication History
http://qheps.health.qld.gov.au/qhmms/home.htm or phone 07 36369095 Fax
07 36369098
Allergies Besides medicines, is there anything else you are allergic to?
For example - bee stings? sticking plaster for dressing? nuts?
What happens? Do you carry an Epi-pen / medication?

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Injuries Have you been involved in an accident? What happened? Did you lose
consciousness? Have you ever tried to hurt yourself on purpose?
Have you ever been assaulted?
Family history Are there any health problems in your family? heart trouble, kidney? diabetes?
high blood pressure? TB, suicide? stroke? mental health problem – such as
depression or schizophrenia? alcohol problem? or problem with drugs?
smoking? obesity? weight loss? skin infections? cancer?
Social history What is your position in the family? Do you have extra / any responsibility
because of your position? How does that affect you?
Do you work? Are you married? Live at home? Where do you live? Who else
lives there? Do you smoke? Do you drink alcohol? On a typical day / week how
much would you drink?
Do you use drugs? smoke, inject? snort? swallow?
Are you worried about these? Have you ever tried to give up?
Cultural history How long have you lived here? Where were you born? What cultural group do
you identify with? What health problems did / have you experienced or exposed
to when you were in the different place/s? Did anything make it better?
Consider - Major beliefs and values. Health beliefs and practices. Language
barriers and communication styles. Role of the family, spouse / partner, and
parenting styles. Religious influences. Dietary practices. Seasonal influences.
[2] What does being healthy mean for you?

Physical examination of patient (adult or child)


Ensure patient privacy. For a comprehensive physical examination a patient maybe
required to remove some or all of their clothing and change into a gown. Consent is
required. Skills to perform physical examination are: [2]
Inspection - is the use of the senses of vision and smell to consciously
observe the patient.
Auscultation - the act of active listening to body organs to gather information on
a patient’s clinical status. Body sounds can be voluntary (deep
breaths) or involuntary (heart sounds). Sounds are described by
their intensity, pitch, duration, quality and location. Equipment
used to assist in auscultation includes – blood pressure machine,
stethoscope (adult and paediatric), pinard’s stethoscope (to listen
to fetal heart in pregnant woman), doppler ultrasound.
Palpation - uses touch in a therapeutic manner to identify specific information.
The palms, fingertips and back of the hands are used. Light and deep
palpation is used.
Percussion - is the technique of striking one object against another to cause a
vibration that produces sound. Identification of air, fluid or solids
can be confirmed and the size, shape and position of an organ.
Percussion sounds are reported according to intensity – loudness or
softness of the sound, duration – the time period over which a
sound is heard and pitch – the highness or lowness of the sound.

Have a systematic approach to physical examination. Know what is normal then it is


easier to identify variations. Document your findings.

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Standard clinical observations


To be performed on each patient who presents for acute care (minimum)
Normal range Normal range
adult child
Pulse rate (heart 60 – 100 bpm Age Beats per minute (mean)
rate) beats per <1day 93 to 154 (123)
minute 1 to 2 days 91 to 159 (123)
3 to 6 days 91 to 166 (129)
1 to 3 weeks 107 to 182 (148)
1 to 2 months 121 to 179 (149)
3 to 5 months 106 to 186 (141)
6 to 11 months 109 to 169 (134)
1 to 2 years 89 to 151 (119)
3 to 4 years 73 to 137 (108)
5 to 7 years 65 to 133 (100)
8 to 11 years 62 to 130 (91)
12 to 15 years 60 to 119 (85)
Blood pressure <140 systolic / 90 diastolic For gender BP breakdown see Acute Post
(BP) systolic and Streptococcal Glomerulonephritis
diastolic 50th percentile blood pressures
Age systolic diastolic
1year 90 60
5 years 95 60
10 years 105 65
15 years 115 65
18 years 120 70
90th percentile blood pressures
Age systolic diastolic
1year 110 75
5 years 115 75
10 years 125 80
15 years 135 85
18 years 140 90
Respiratory rate 12-20 bpm Age Breaths per minute
(resps) breaths 0 to 1 year 24 to 38 bpm
per minute 1 to 3 years 22 to 30 bpm
4 to 6 years 20 to 24 bpm
(One breath in
and out = 1 7 to 9 years 18 to 24 bpm
breath) 10 to 14 years 16 to 22 bpm
14 to 18 years 14 to 20 bpm
Temperature Oral 36 -38 °C
(temp) – axilla, Axilla 35.4 -37.4 °C
under tongue, ear, Ear 36 -38 ° C
in degree celsius Rectal 36.7-38 ° C
°C

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If indicated also perform with standard clinical observations


Blood glucose level 4-8 mmol / L (random capillary)
(BGL)
Urinalysis (U/A) Record results of dipstick
Specific gravity, pH, protein, leucocytes, blood ketones
Oxygen saturation PaSO2 > 94%
(PaSO2) PaSO2 90 – 92% for patients with COPD and chronic hypoxia
Body measurements
Normal range - adult Normal range - child
Height Plot on growth chart for age and gender Plot on growth chart for age and
gender
Weight Plot on growth chart for age and gender Plot on growth chart for age and
Record on medication chart gender AND on medication chart
Waist circumference Adults Not applicable for children
Men Women Risk
< 94 cm < 80 cm Low
94-101 cm 80-87 cm High
• 102 cm • 88 cm Very high
General appearance
Inspection • Identify if patient meets stated versus apparent age
• Body fat / distribution?
• Stature – their posture, body proportions (are their limbs in proportion to
body)
• Facial features – is there anything significant? (consider foetal alcohol
spectrum disorder). Facial expressions?
• Motor activity – the way the person walks (gait and speed), weight bearing
– are they favouring or guarding parts of their body? Is there decreased
movement in any part of the body?
• Body and breath odours
• How is the person groomed? dressed? personal hygiene?
• What is the persons mood? manner?
• Verbal and non-verbal body language?
• Is the person distressed? physically? psychological or emotionally?

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Neurological For detailed mental status examination (MSE) see Mental Health section.
system Conscious state:
(mental and 1. AVPU - A – alert / V – responds to verbal statement / P – responds to
conscious state) painful stimuli / U – no response (unresponsive)
2. Glasgow coma scale (adult, child, infant)
Glasgow coma scale (GCS)– adult, child and infant
Adult Child Infant
Child > 5 years 2-5 years 0-23 months
Eyes Open 4. Opens eyes spontaneously
3. Opens eyes on command or to speech
2. Opens eyes with pain (pinching)
1. No eye opening/no response
Best Verbal 5. Fully orientated 5. Appropriate 5. Smiles, coos, cries
Response 4. Confused, words and appropriately
disorientated: phrases 4. Cries but consolable
not sure of their name 4. Inappropriate 3. Persistent cries and/or
or where words screams
they are or what 3. Cries and/or 2. Grunts
happened screams 1. No response
3. Inappropriate: 2. Grunts
meaningless words 1. No response
2. Incomprehensible
noises: grunts, moans
1. No sounds
Best Motor 6. Obeys commands 6. Obeys commands
Response 5. Localises to pain 5. Localises pain
4. Withdraws to pain 4. Withdraws to stimuli
3. Flexor response to pain (bends arm or leg) 3. Abnormal flexion
2. Extensor response to pain (straightens arm or 2. Extensor responses
leg) 1. No response
1. No response
Score Maximum score= Eyes 4 + Verbal 5 + Motor 6 = 15 (fully alert, conscious)
Minimum score = Eyes 1+Verbal 1+Motor 1 = 3 (unconscious)
Always act - on score less than 14 / act immediately on a score of 13 or
less in a child / drop of 2 or more from last assessment / if less than 8
consider intubation
GCS not valid if – patient has - direct eye injury or periorbital swelling after head trauma; intubated
patients; immobilised limbs. In these situations it is appropriate to record the individual scores for each
measurable response (motor, verbal or eyes) [3]

Skin
Inspect Through out physical examination note:
• Colour, bleeding, bruising, rashes
• Vascularity (presence of lesions – skin tags, sores, scabies, fungal
infection, skin cancers
Palpate • Moisture - sweating, dry
• Temperature - cool, warm, hot?
• Texture - is the skin thin / thick?
• Turgor - (elasticity / amount of fluid in skin), normal turgor is when fully

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hydrated and skin snaps back to normal position; decreased skin turgor is
a late sign of dehydration. It is normal for skin turgor to decrease as skin
ages.
• Oedema - excessive fluid in subcutaneous tissues
Head and face
Inspect • The shape of the head
• Head and scalp
• Colour and distribution of hair – note any head lice, nits
• Face – eyes (position), eyebrows, ears, nose and mouth
Palpate • Head and scalp
• Lymph nodes
Eyes
Inspect • Eye lids, conjunctiva, sclera, cornea, iris, pupil, lens
Test • Visual acuity – near and distant
• Corneal reflexes
• Cover test
• Red eye reflex
If skilled • Look at the back of the eye with ophthalmoscope
Ears
Inspect • External ear – alignment, shape, colour, size and any lesions of pinna
• Ear canal, tympanic membrane (ear drum), middle ear with otoscope.
Note discharge, swelling, signs of infection, fungal infections, lumps or
bony growths, foreign body, wax
Palpate • External ear
• Mastoid bone
• Lymph nodes of neck
Test if skilled • Hearing with audiometer
• Middle ear function with tympanometer
Nose and sinuses
Inspect • The external surface of the nose
• Is the nose patent? (can the patient breath through their nose?)
• Frontal and maxillary sinuses
• Is there any discharge / foreign body?
Palpate • Frontal and maxillary sinuses (above eyebrow and each side of nose to
cheeks)
Percuss • Frontal and maxillary sinuses (above eyebrow and each side of nose to
cheeks). Tap middle finger of one hand to the middle finger of other hand
placed over the sinus. Does it make a dull or hallow sound?
Mouth and throat
Inspect • Note breath odour
• Lips, mucosa of mouth
• Gums, hard and soft palate (if applicable)
• Tongue – ask the patient to stick their tongue out
• Tonsils – swollen, red?
• Ask the patient if they have any trouble with taste? swallow? gagging?
reflux?
Palpate • Lips and mouth if indicated

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Neck
Inspect • Skin of neck – colour, lesions
• Muscles of neck – are they extended?
• The trachea – is it central? to one side?
• The thyroid – is it enlarged?
• The lymph nodes / glands– in front of the ears, behind the ears, under
jaw, chin, lower jaw, tonsillar area, above and below clavicle
Palpate • Muscles of the neck, is there any swelling? can the patient lift their
shoulders?
• The trachea
• The carotid arteries – one at a time
• The thyroid – stand in front or behind patient and feel
• The lymph nodes / glands– in front of the ears, behind the ears, under
jaw, chin, lower jaw, tonsillar area, above and below clavicle
If skilled Inspect the jugular vein for distension, and estimate the venous pressure (JVP)
if indicated
Arms & hands
Inspect • Nail bed – colour – pink, blue? Shape – clubbing can occur as a result of
long term hypoxia
• Muscle size, upper and lower arm
• Presence of lesions
Palpate • Texture of nail bed or nail
• Joints of fingers, writs, elbows and shoulders
• Temperature
• Radial and brachial pulses
Assess • Range of motion and strength of fingers, wrists, elbows and shoulders
If skilled • Assess capillary refill on nail bed as an indication of peripheral circulation
• Check capillary refill by pressing on the nail until blanching occurs.
Capillary refill Release the nail and count the time for the nail to return to its previous
colour. Check capillary refill on all extremities
• Normal capillary refill is 2- 3 sec. A delayed capillary refill may occur with
heart failure, shock or peripheral vascular disease
Upper back of chest (posterior thorax)
Inspect • Cervical, thoracic, lumbar spine
• Size and shape of chest wall
• Size, shape and position of shoulders, scapula
Auscultate • The posterior thorax and lateral thorax (chest)
Palpate • Cervical, thoracic, lumbar spine
Percuss • The posterior thorax and lateral thorax (chest)
If skilled • Palpate the thyroid (posterior approach)
• Perform diaphragmatic expansion -is there equal expansion of both sides
Upper front of chest (anterior thorax)
Inspect • Size, shape of chest wall
• Angle of ribs, intercostal spaces
• Muscles used for respiration, is the sternum being retracted? muscles
between ribs? muscles of neck?
• Respirations
• Count the respirations (One breath in and out = 1 bpm)

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Auscultate • The anterior thorax (chest wall)


Palpate • The anterior thorax (chest wall)
Percuss • The anterior thorax (chest wall)
If skilled • Perform anterior thoracic expansion-is there equal expansion of both
sides?
Heart
Inspect • Chest wall, pulses in neck
Auscultate (with bell • The apical (apex) of the heart
of stethoscope) • Describe, sounds – rhythm, rate
• Count the pulse
If skilled • Palpate the cardiac landmarks for pulsations, thrills, and heaves
Female breasts as appropriate to presentation by skilled practitioner
Inspect • Breasts for colour, size, shape, equal on both sides? Any obvious
discharge?
• Lesions / thickening / oedema
Palpate • Both breasts and
• Lymph nodes – under arm, pectoral, clavicle
If skilled • Teach breast self examination
Male breasts as appropriate to presentation by skilled practitioner
Inspect • Breasts for colour, size, shape, equal on both sides? Any obvious
discharge?
• Lesions / thickening / oedema
Palpate • Both breasts
• Lymph nodes – under arm, pectoral, clavicle
If skilled • Teach breast self examination
Abdomen
Inspect • The size, shape, colour and pigmentation
• Note – scars, stretch marks, visible peristalsis, masses, pulsation
• Umbilicus
Auscultate • Bowel sounds - describe
Percuss • Quadrants of the abdomen
• Note – liver span and descent
• Spleen, stomach and bladder
Palpate • Palpate lightly all quadrants of the abdomen
• Note any guarding
• Palpate (deeply) if skilled
• Liver, spleen, kidney, aorta and bladder
Inguinal area
Inspect • Inguinal lymph nodes
• For inguinal hernias
Palpate • Inguinal lymph nodes
• Femoral pulses
Legs and feet
Inspect • Colour, oedema, lesions, scars, hair distribution, varicose veins
• Muscle size upper and lower leg and feet – are they equal?
Palpate • Temperature, oedema,
• Texture skin and nails
• Pulses – popliteal, dorsalis pedis, posterior tibial pulses
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• Muscles legs and feet
• Joints of the hips, knees, ankles and feet
Assess • Range of movement – hips, knees, ankles and feet
If skilled • Check capillary refill (as per arms & hands)
Female genitalia, anus and rectum as appropriate to presentation by skilled practitioner
See Health Check – Women
Male genitalia as appropriate to presentation by skilled practitioner
Inspect • Hair distribution, penis, scrotum
• Urethral meatus for discharge, location on head of penis
Palpate • Penis, urethral meatus and scrotum
• Inguinal area for hernias
If skilled Teach testicular self examination
Male anus, rectum and prostate as appropriate to presentation by skilled practitioner
Inspect • The perineum, sacrococcygeal area, anal mucosa
Palpate (if skilled) • The anus, rectum and prostate

Diagnostic and pathology services


Diagnostic and pathology services are limited in rural and remote facilities.

Patients may be required to travel in order to access some diagnostic services.


Visiting outreach services including those provided by the RFDS may also bring portable
diagnostic devices to the patient.

Refer to the current edition of the Pathology Handbook for Rural and Remote Queensland
for information on ordering of pathology tests, labelling, collection of specimens,
pre-laboratory processing, transport of specimens and accessing of results.

It is very important when diagnostic tests have been performed that the results are
followed up, the patient informed of the results and abnormal results acted on. Consult a
Medical Officer for advice if unsure about results. MO must review all abnormal results.

Collaboration with other members of the team

To ensure the patient receives the appropriate care for their condition, collaborating with
other members of the team, often by remote consultation, is required.

Collaborative practice is the term used to describe the practice relationship between Registered
Nurses, Medical Practitioners, Aboriginal and Torres Strait Islander Health Workers and other
health professionals who use the PCCM as a guide to practice. The collaborative practice
relationship incorporates the dual notions of collaboration and delegation.

The defining characteristics of the collaborative practice relationship are:


• Mutual respect and acknowledgment of each profession’s role, scope of practice and
unique contribution to health outcomes
• Clearly stated protocols and guidelines for clinical decision-making which comply with
relevant legislation and are supported by the health facility and the health organisation
• Clearly defined levels of accountability with an acceptance that joint clinical decision-
making is an integral component of collaborative practice
• A belief that the best health outcomes are achieved when well prepared health
professionals work in collaboration and partnership in both the practice and
educational setting

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Royal Flying Doctor Service (RFDS)


and
Queensland Emergency Medical System (QEMS) Coordination Centres

Queensland RFDS is part of the Queensland Emergency Medical System (QEMS) with
Queensland Health (QH), Queensland Ambulance Service (QAS) and Queensland
Department of Emergency Services (DES). This integrated system includes road
transport, rotary and fixed wing aircraft and reduces the impact of time and distance on the
treatment of sick and injured patients living, working or travelling in Queensland.

Queensland RFDS provides services from its network of strategically located Bases in
Brisbane, Bundaberg, Cairns, Charleville, Longreach, Mt Isa, Rockhampton and
Townsville. All RFDS Bases in Queensland, except Longreach provide aero-medical
retrieval / transport service. The RFDS Longreach base provides mental health service to
people living in central western Queensland.

Fixed-wing RFDS aircraft based in Cairns, Charleville and Mt Isa are coordinated by
RFDS Medical Officers. Fixed-wing RFDS aircraft based in Brisbane, Bundaberg,
Rockhampton and Townsville are coordinated by the QEMS Coordination Centres (QCC).

The QCC is a collaboration between Queensland Health’s Retrieval Services Queensland


(RSQ) and the Department of Emergency Services’ QAS. With centres in Brisbane and
Townsville, the QCC has oversight for all Primary (000) and Interfacility aeromedical
retrievals and transfers of adult, paediatric, neonatal and high risk obstetric patients
throughout Queensland. RSQ Medical Coordinators provide clinical guidance in retrieval
decisions and clinical support to referring clinicians regarding patients requiring aero-
medical and some road transfers.

RFDS Mission Statement


Providing excellence in aeromedical and primary health care across Australia

Services provided by RFDS (Queensland Section)

1. Provision of routine and emergency medical advice and clinical support to Registered
Nurses and Aboriginal and Torres Strait Islander Health Workers
• Routine and emergency medical advice can be obtained 24 hours a day from
your nearest RFDS Base with RFDS Medical Officers (Cairns, Charleville and
Mt Isa ) by telephoning one of the contact numbers
• Rural and Isolated Practice Endorsed Registered Nurses and Authorised
Aboriginal and Torres Strait Islander Health Workers should consult with the
appropriate local Medical Officer or nearest RFDS Medical Officer as stipulated
by Health Management Protocol (HMP) and Clinical Care Guideline (CCG)
detailed in the PCCM. Other Registered Nurses are encouraged to use the
PCCM as a guide to their practice and consult as required and in accordance
with Health (Drugs and Poisons) Regulation 1996
• All requests for medical advice should be accompanied by clear presentation of
an appropriate history and examination, including basic observations as detailed
in clinical assessment and history taking section of the PCCM. It is preferable to
have the patient present in case further information is required by the Medical
Officer

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• In rural and remote areas of north and western Queensland the RFDS also
provides primary care services through a network of clinic locations. Clinic
locations range from Queensland Health facilities with no resident doctor, to
small isolated properties and mines

2. Provision of advice regarding patient retrieval and transport


• Health professionals unsure of the patient transport requirements may seek the
advice of an RFDS Medical Officer (Cairns, Charleville, Mt Isa) or RSQ Medical
Coordinator (Brisbane, Townsville). In most cases there are several options for
management and several potential methods of transport which can be explored.
All RFDS Medical Officers and RSQ Medical Coordinators are experienced in
providing this kind of practical support
• It is preferable to make contact early, even if transport requirement is not
confirmed, as this allows more efficient use of resources

3. Coordination of patient retrieval and transport using RFDS aircraft (and other
available resources)
• RFDS Medical Officers and RSQ Medical Coordinators are able to task RFDS
fixed wing aircraft or make use of other available resources as appropriate. All
patient transports are prioritised according to clinical need and availability of local
resources. Less urgent cases may be delayed to facilitate the transfer of urgent
cases from other locations

Consulting the Medical Officer

If it is necessary to consult with a Medical Officer (MO), try to present your findings in a
clear and methodical way.
• It is often easier if you write your findings down first (time permitting)
• It is helpful to advise the MO early that you have a patient about whom you want some
advice or alternately who you think may need evacuation
• Begin with the name and age of the patient, then the presenting concern and proceed
through the patient history, clinical observations and physical examination findings
• Say what you think is wrong – your assessment is important; after all, you are actually
with the patient
• Always consult with the MO if you are not sure. Take the opportunity to discuss
general or specific cases or issues with the MO at the next clinic visit

What to tell the RFDS Medical Officer or RSQ Medical Coordinator

1. Appropriate clinical information:


• Patient name, DOB, gender, weight, specific location
• Details of patient history obtained including current medications & allergies
• Clinical observations, physical examination and investigation findings
• Management commenced, including drugs administered and infusions in
progress
• Intravenous lines, drains, catheters, splints, dressings

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Patient assessment and transport

2. Change in clinical condition:


• Please inform the RFDS Medical Officer or RSQ Medical Coordinator of any
change to the clinical condition of the patient (worsening or improving) in order
that flight priority can be appropriately reassessed.
• Note: a MO does not accompany all RFDS flights. If a patient’s condition worsens
it may be necessary for an MO to accompany the flight when it was not originally
planned to do so.

3. Admission details
• If the referring health professional is a Registered Nurse (RN) / Aboriginal and
Torres Strait Islander Health Worker (IHW), the RFDS Medical Officer or RSQ
Medical Coordinator will organise admission to an appropriate facility. Otherwise,
the following information is also required:
− reason for inter-hospital transfer
− receiving hospital and unit (bed availability must be confirmed prior to transfer)
− name of accepting doctor

What the RFDS Medical Officer or RSQ Medical Coordinator will tell you

1. Requirements
The RFDS Medical Officer or RSQ Medical Coordinator will discuss the patient and
confirm any requirements. Please ask if there is anything you are unsure about

2. Timeframe
A planned time frame will be given but accurate estimated time of arrival (ETA) will not
be confirmed until the aircraft is in flight. Retrievals and patient transports are
prioritised and timing is subject to amendment

3. Priority
You will be informed of significant change to planned activity such as another
more urgent case taking priority

How to prepare a patient for transport

1. General Considerations
• All patients must be adequately prepared and stabilised prior to transport. In many
cases this can be done prior to arrival of the RFDS team
• Please discuss with the RFDS Medical Officer or RSQ Medical Coordinator as
required
• Complete the RFDS Aeromedical Retrieval Checklist. This is to be completed
for all patients requiring transport with the RFDS

2. Specific Clinical Conditions


• Many patients require preparation specific to transport and the aero-medical
environment. The following table illustrates some clinical conditions of particular
importance.
• Please discuss with the RFDS Medical Officer or RSQ Medical Coordinator as
required.
See following table for further detail.

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Patient assessment and transport

General
Rationale Requirement
Considerations
All patients must be accompanied by
appropriate documentation including:
• referral letter
Documentation is
• copy of medical / nursing records
required by the flight
crew and by the
• pathology results
Documentation
receiving facility in order • ECG print out
to provide appropriate • X-rays
ongoing care (where digital radiology is available, if
possible, ensure the electronic transfer
of x-rays to the receiving facility has
occurred)
Any transfer involves • The patient should receive analgesia
movement of the patient, prior to transfer
Analgesia
which may exacerbate • See Pain management inter-facility
pain transfer HMP or consult MO
• Routine use of antiemetics is not
indicated
• Vomiting will • Antiemetics considered if there history
potentially exacerbate of motion sickness
certain clinical
• Promethazine or prochlorperazine is
conditions by raising
preferred for motion sickness given 30
intracranial and
minutes prior to transfer
Antiemetic intraocular pressure
and placing the airway • Parenteral administration of an
at risk antiemetic is essential for patients with
head, spinal injury or penetrating eye
• Motion sickness is
injury
common in the aero-
medical environment • For general nausea consider
metoclopramide or ondansetron
• Consult MO
• The RFDS carries a
comprehensive but
limited range of drugs
Parenteral • Infusions are • Please prepare infusions prior to
drug administered using
transfer using RFDS compatible
infusion infusion pumps or
equipment if possible
syringe pumps. Time
is saved if infusion is
prepared prior to
RFDS arrival
• All ventilated patients and
Nasogastric / orogastric
patients with bowel obstruction should
catheters allow drainage
have an NGT/OGT inserted and
of stomach contents and
Nasogastric secured prior to transfer
reduce the risk of
catheter
vomiting and aspiration
• Conscious, alert and cooperative
spinal injured patients do not require a
nasogastric tube
• Consult MO

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Patient assessment and transport

General
Rationale Requirement
Considerations
• A urinary catheter is required for
There are no toilet facilities on all incontinent or potentially
RFDS aircraft. The use of incontinent patients. Those who
Urinary
bedpans is avoided due to wear a continence pad may not
catheter
limitations of space and waste require catheterisation
disposal • All patients should have their
bladders empty prior to transfer
• Critically ill and disturbed patients
Venous access may be should have 2 patent IV cannulae
Venous difficult to achieve during inserted and secured prior to
cannula transfer due to space transfer
limitations and turbulence • The majority of patients should
have one IV cannula
Confined space in the aircraft Advise RFDS Medical Officer/ RSQ
Infectious limits the ability to isolate Nursing or RSQ Medical
conditions patients with infectious Coordinators of infectious conditions
conditions when requesting aerial transfer
• Seating availability is often
limited, particularly if more
than one patient is carried
Patient • There are strict weight An escort will be carried if possible,
escort restrictions for take off and at the discretion of the pilot
landing which influence
amount of fuel and
passengers numbers
• Space and weight
• Maximum baggage allowance is 1
restrictions limit the
small bag with a weight of 8 kg
capacity to carry baggage
(B200 aircraft) and 5kg (PC12
Baggage • Baggage is carried in the aircraft)
same area as medical
• Medical aids and additional
equipment, which must be
baggage will be carried at the
easily accessible at all
pilot’s discretion
times
• Patients who have been
appropriately stabilised and
prepared may be handed over to
Where clinically appropriate,
the RFDS crew at the airport
Handover airport handover of the patient
location reduces time and increases • Critical and unstable patients will
aircraft availability be retrieved from the health
facility. Handover location will be
discussed during the coordination
process

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Patient assessment and transport

Special
Rationale Requirement
Considerations
• All patients with proven or • All ventilated spinal injured
suspected spinal injuries are patients require a nasogastric
transported on a vacuum tube
Spinal injury
mattress • A nasogastric tube should be
• Insertion of a urinary catheter is considered for all spinal injured
necessary to monitor urine patients who are uncooperative or
output and maintain have an altered level of
immobilisation consciousness. Consult MO
• All patients with bowel obstruction
should have a nasogastric
• Trapped gas will expand in
catheter inserted. Leave
volume at altitude and cause
nasogastric tube on free drainage
Bowel pain
or attach anti-reflux valve. Do not
obstruction • A nasogastric catheter may
spigot nasogastric tube
allow escape of trapped gas
• Administer parenteral antiemetic
and reduce vomiting
as indicated and adequate
analgesia prior to transfer
• Trapped gas in the pleural • All patients with proven
cavity will expand at altitude pneumothorax should have an
and may result in respiratory intercostal catheter inserted and
Pneumothorax compromise (Underwater seal connected to a Heimlich valve or
drains are avoided due to the Portex ambulatory chest drainage
risk of retrograde flow during system. Suspected pneumothorax
transfer) must be excluded by X-ray
• All patients with proven or
• Trapped gas in the globe will
suspected penetrating eye injury
expand at altitude and
must receive a parenteral
Penetrating eye potentially worsen the injury
antiemetic
injury • Vomiting may also worsen
• They will be transported at
injury by raising intraocular
reduced cabin altitude
pressure
• Mental health emergency patients
are transported in daylight hours
with no other patients on board the
• Mental health emergency aircraft. They require physical
patients are a potential threat to restraint and reliable intravenous
aviation safety access +/- appropriate sedation
Mental illness
• Appropriate physical +/- • A Medical Officer or additional
chemical restraint is used to escort trained in restraint is also
reduce this threat required
• All cases must be discussed in full
with the RFDS Medical Officer or
RSQ Medical Coordinator

Primary Clinical Care Manual 2009 Page 25


Patient assessment and transport

Special
Rationale Requirement
Considerations

• An aircraft is not an
appropriate place for
delivery
Women in • Transport may occur if • All cases must be discussed in full
labour is suppressed, with the RFDS Medical Officer or
labour
otherwise it may be more RSQ Medical Coordinator
appropriate to deliver
locally and transport mother
and baby as required

• Patients with haemoglobin


• Anaemia reduces the
concentration of less than 70 g/L
oxygen carrying capacity of
should ideally be transfused prior to
the blood. This is
Anaemia transfer. All cases must be
exacerbated at altitude due
discussed in full with the RFDS
to the reduced partial
Medical Officer or RSQ Medical
pressure of oxygen
Coordinator

References

1. Queensland Nursing Council. Professional documentation standards information


sheet no. 3. 2005 [cited 10/6/09]; Available from: www.qnc.qld.gov.au.
2. Estes M and Schaefer KP, Health assessment & physical examination. 2nd ed. 2002,
Albany, NY: Delmar.
3. Therapeutic Guidelines, Trauma primary survey: initial neurological assessment.
2008, Therapeutic Guidelines Ltd: Melbourne.
Page 26 Primary Clinical Care Manual 2009
Patient assessment and transport

If required, originals of this document can be obtained from your nearest RFDS service

Primary Clinical Care Manual 2009 Page 27


Patient assessment and transport

 Pain management for inter-facility transfer


(Adult)
This HMP is for inter-facility transfers initiated by a Medical Officer within an
Isolated Practice Area as defined by the Health (Drugs and poisons) Regulation
1996
Recommend
™ Where a clinical condition has been identified follow the appropriate HMP
™ Patients in pain receive analgesia in a timely and safe manner to achieve comfort
™ The aim of pain control is to achieve patient comfort, it is not always possible to
achieve a pain score of 0 and patients are often ‘comfortable’ with a pain score of 0 –
3, thus it is appropriate to ask the patient “are you comfortable” rather than ‘are you in
pain” ie do not give the expectation of achieving ‘zero’ pain.
™ Pain intensity – the best scientific tool for measuring pain intensity is the patient’s self
report using a pain rating scale. The most commonly used measurement tool is the
numeric pain score 0-10. The self reported pain score is used in conjunction with
clinical assessment
™ Research indicates that the elderly may find it easier to describe their pain as mild,
moderate or severe, rather than using a numerical pain score.
Background
™ Pain is defined as “an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage”. [1] Pain is
highly subjective to the individual experiencing it and is the most frequent reason for
people seeking health care professional consultation.

Related topics:
Glasgow coma scale, page 15
 Poisoning and drug emergencies (Opiates), page 194

1. May present with:


• Self report of pain
• Pre-existing medical condition causing pain
• Increased heart rate, respiratory rate and blood pressure
• History of pain related to medical condition
• Pallor, muscle tension/guarding, sweating
• Dilated pupils
• Nausea/vomiting
• Emotional responses (crying, screaming, anger, grimacing)

2. Immediate management:
• Identify the patients self reported level of pain 1-10 and pre-existing medical
condition / complaint

No pain Mild Moderate Severe Worst possible pain

0 1 2 3 4 5 6 7 8 9 10

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Patient assessment and transport

3. Clinical assessment:
• Obtain patient history including presenting complaint – e.g. cancer patient
• Perform standard clinical observations + Glasgow coma scale (GCS)
• Inspect the size of the patient’s pupils
• Is the patient able to swallow?
• Do they have a patent IV cannula insitu?
• Obtain history of current episode of pain
− onset and duration (when did it start? gradual or sudden onset?)
− duration (how long has the patient had the pain? have they experienced
pain like this before?)
− intensity (using a scale of 1-10 with 0 being no pain and 10 being the
worst pain you can imagine, rate the pain you are experiencing now? [2]
− site and radiation (eg. where is the pain? Does the pain go elsewhere?)
− character (eg. sharp pain, dull pain, burning pain)
− associated features (eg. nausea, vomiting)
− what makes it better or worse (eg. Lying down, sitting up)
• Previous methods / analgesics used to control pain? what has worked / what
hasn’t? has there been any side effects?
• Take medication history – current medications / allergies / is the patient taking
any over the counter medications?

Sedation Score
0 = awake
1 = mildly drowsy, responsive to voice stimuli
2 = moderately drowsy, responds to touch only
3 = severely drowsy, not responding

4. Management:
• Perform GCS, BP, pulse, respirations and pain score and sedation score prior to
and post administration of analgesia
• If further doses are required, GCS must be 14 or above, systolic blood pressure
>90mmHg, respiratory rate >10 and sedation score 1 or less prior to each dose
• Consult MO if observations outside these parameters
• If patient develops a depressed level of consciousness, respiratory depression
or severe hypotension following the administration of Morphine or Fentanyl see
Poisoning and drug emergencies (opiates)
• Monitor vital signs, pain score and sedation scores at intervals appropriate to
analgesia given
Pain score 1-3, and clinical assessment indicates mild pain. If not allergic
consider paracetamol (paracetamol is rapidly absorbed after oral administration, with
a peak concentration in 10 to 60 minutes)

Primary Clinical Care Manual 2009 Page 29


Patient assessment and transport

DTP
Schedule 2 Paracetamol
NP / IHW
Authorised Indigenous Health Workers may proceed
Nurse Practitioner may proceed
Route of
Form Strength Recommended Dosage Duration
Administration
Tablet 500mg Oral Adults: 1-2 tabs every 4 Stat and as ordered
hrs to maximum 8 by MO or NP up to
tabs/day 48 hours only
Provide Consumer Medicine Information if available:
Management of Associated Emergency: Consult MO
OR
Pain score 4-6, and clinical assessment indicates moderate pain. If not allergic
consider give paracetamol 500mg / codeine phosphate 30mgs. (Codeine is well
absorbed from the gastrointestinal track peak onset of action is 1-2 hours). [3]
And / or
If not allergic and does not have asthma, renal disease, heart disease, GI bleeding
conditions, dehydration, in the 3rd trimester of pregnancy, lactation, significant liver
disease or coagulation disorder or on ACE-inhibitors, diuretics, warfarin, lithium
consider Ibuprofen
DTP
Schedule 4 Ibuprofen
NP / IHW
Authorised Indigenous Health Workers may proceed
Nurse Practitioner may proceed
Route of Recommended
Form Strength Duration
Administration Dosage
Tablet 400mg Oral Adult: 400 mg Stat and repeat in 6
hours if required
Precautions – do not use in patients with - asthma, renal disease, heart disease, GI bleeding
conditions, dehydration, in the 3rd trimester of pregnancy, lactation, or on ACE-inhibitors, diuretics,
warfarin, lithium
Provide Consumer Medicine Information if available
Management of Associated Emergency: Consult MO see Poisoning: Opiates HMP

Schedule 4 Paracetamol 500mg / DTP


codeine phosphate 30mg NP / RIN / IHW
Authorised Indigenous Health Workers & Isolated Area Paramedics must consult MO
Rural and isolated practice nurses may proceed
Nurse Practitioner may proceed
Route of Recommended
Form Strength Duration
Administration Dosage
Tablet Paracetamol Oral Adult: 1-2 tabs Stat and repeat in 4
500mg / Codeine hours if required
Phosphate 30mg
Precautions – CNS depressant
Provide Consumer Medicine Information if available: may cause drowsiness, GI upset, nausea /
vomiting, constipation, dizziness, bronchospasm
Management of Associated Emergency: Consult MO see Poisoning: Opiates HMP
Page 30 Primary Clinical Care Manual 2009
Patient assessment and transport
OR
Pain score 7-10, and clinical assessment indicates severe pain, no allergies and has a
systolic blood pressure over 90 mm Hg and a respiratory rate over 10 breaths per minute
and has a sedation score of 1 or less give IVI or IMI Morphine. If sedation score of 2 or
more do not give. Caution in elderly and those with significant renal / liver disease.
Fentanyl is more appropriate

• Insert IV cannula if required


• Give metoclopramide if nauseated or vomiting

DTP
Schedule 4 Metoclopramide
IHW / RIN / NP
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Route of Recommended
Form Strength Duration
Administration Dosage
Ampoule 10 mg in 2 mL IM Adults only: Stat
or 10 mg Further doses should
IV (IHW may not only be given on MO’s
administer IV) orders
Provide Consumer Medicine Information if available: Not for use in patients with Parkinson’s disease or children
and caution in use in women less than 20 years of age
Management of Associated Emergency: Dystonic reactions eg. oculogyric crisis are extremely rare (unless
repeated doses or in children). If oculogyric crisis develops give Benztropine 2 mg IMI or IVI as per Mental
health emergencies


DTP
Schedule 8 Morphine Sulphate
IHW / RIN / NP
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Route of
Form Strength Recommended Dosage Duration
Administration
Ampoule 10 mg/mL IM Adults only: 0.1-0.2 mg/kg up to Stat
a maximum of 10 mg Consult the Medical
Ampoule 10 mg/mL IV Adults only: 2.5 mg increments Officer if the patient
(IHW may not slowly, repeated every 10 min if requires more than the
administer IV) required to a maximum of 10 mg recommended dose
Provide Consumer Medicine Information if available: Advise can cause nausea and vomiting, drowsiness
Management of Associated Emergency: caution – in the elderly and those with significant renal / liver disease -
Respiratory depression is rare. If it should occur give Naloxone as per Poisoning: Opiates HMP NB: as
Naloxone counteracts the narcotic, it may cause the return of severe pain

Primary Clinical Care Manual 2009 Page 31


Patient assessment and transport

If allergic to Morphine or significant renal disease give Fentanyl: N.B. Fentanyl has a rapid
onset of action
DTP
Schedule 8 Fentanyl
IHW / RIN / NP
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Route of
Form Strength Recommended Dosage Duration
Administration
Ampoule 100 IM Adults only: 1.5 Stat. Consult the MO if
microgram/ micrograms / kg / dose up the patient requires
2 mL to a maximum of 100 more than the
microgram recommended dose
Ampoule 100 IV Adults only: 25 microgram Stat. Consult the MO if
microgram/ (IHW may not increments slowly, the patient requires
2 mL administer IV) repeated every 10 min if more than the
required to a max. of 100 recommended dose
microgram
Ampoule 100 Intranasal Adult only Stat. Consult the MO if
microgram/ 1.5 microgram/kg the patient requires
2 mL undiluted up to a maximum more than the
of 100 microgram recommended dose
Administration instructions for intranasal fentanyl. Draw up dose into 1ml or 2 ml syringe. If using a
mucosal atomisation device (MAD) attach to the syringe. Position patient sitting up at a 45 degree
angle or with head resting to one side. Position the atomiser or syringe into the nostril loosely, aiming
for the centre of the nasal cavity. Depress the syringe plunger quickly. If 100microgram / 2 ml is being
used split the dose between both nostrils to minimise loss due to sneezing or swallowing.
Intranasal fentanyl may be unreliable if patient has blocked nose.
Provide Consumer Medicine Information if available: Advise can cause nausea and vomiting, drowsiness
Management of Associated Emergency:
Respiratory depression is rare. If it should occur give Naloxone as per Poisoning: Opiates HMP NB: as
Naloxone counteracts the narcotic, it may cause the return of severe pain

5. Follow up:
 Monitor patient’s response to analgesia and document vital signs including GCS, BP,
pulse and respirations, pain and sedation score
 If sedation score is 3 or respiratory rate < 8 administer Naloxone give O via Hudson
mask and consider need to assisted ventilation ie bag/valve/mask.

6. Referral / Consultation:
 Consult MO if further analgesia is required and maximum dose has been administered

References
1. International Association for the Study of Pain Subcommittee on Taxonomy, Classification of
chronic pain syndromes and definitions of pain terms. Pain, 1986. 3(Suppl. 3): p. S1-S226.
2. Estes M and Schaefer KP, Health assessment & physical examination. 2nd ed. 2002,
Albany, NY: Delmar.
3. MIMS Online. Prescribing information. 2009 [cited 14/5/09]; Available from: https://www-
mims-hcn-net-au.

Page 32 Primary Clinical Care Manual 2009