(PLACE PATIENT LABEL HERE)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                       SURNAME: ____________________________________    NHI: _____________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                       FIRST NAMES: ____________________________________________________
                                                                                                                                      ✓                                                                                  ✗                                                                                                                                                                                                                                             Date of Birth: _______ /_______ /_______                           SEX: _____________
                                                                                                                                                      = YES                                                                             = NO  
                                                                                                                                                                                                                                                                                                                                                                            LOWER BACK PAIN
                                                                                     DDDDDaaaaattttteeeee:::::                                             /////                                             /////     2222200000                                                  TTTTTiiiiimememememe:::::                                                                 CCCCCllllliiiiinnnnniiiiiciciciciciaaaaannnnn:::::                                                                                                                                                                                                                                                                        CCCCCNNNNNS S S S S                                           NP  NP  NP  NP  NP                                            HHHHHS S S S S                                     Reg    Reg    Reg    Reg    Reg                                           SMOSMOSMOSMOSMO
                                                                                                  HISTHISTHISTHISTHISTORORORORORYYYYY     AND PRESENTING COMPLAINT  AND PRESENTING COMPLAINT  AND PRESENTING COMPLAINT  AND PRESENTING COMPLAINT  AND PRESENTING COMPLAINT  
                                                                                                          Mechanism / onset:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Ask about traumaAsk about traumaAsk about trauma
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 No aggravating / relieving No aggravating / relieving No aggravating / relieving 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                factors: ? AAA or spinal factors: ? AAA or spinal factors: ? AAA or spinal 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         infectionsinfectionsinfections
                                                                                                            Location / duration:
                                                                                                                                 24 hour pattern:
                                                                                                       Aggravating factors:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        MEDICINE NOTES
                                                                                                                        Relieving factors:       
                                                                                                  SCREEN FOR IMPORTSCREEN FOR IMPORTSCREEN FOR IMPORTSCREEN FOR IMPORTSCREEN FOR IMPORTANT CLINICALANT CLINICALANT CLINICALANT CLINICALANT CLINICAL SYNDROMES SYNDROMES SYNDROMES SYNDROMES SYNDROMES
                                                                                         CCaauuddaa  EqEquuiinnaa                                                                                                                                                                                                            Tumour                                                                                                                                                                                                                                                        Infection                                                                                                                                                                                      Other
                                                                                                                 UUririnnaary ry reretteennttiioonn                                                                                                                                                                                                History of cancer                                                                                                                                                                                                                                             Fever                                                                                                                                                                                          Abdominal pain
                                                                                                                 IInncocompmplleettee  vovoiiddiinngg                                                                                                                                                                                              Night sweats                                                                                                                                                                                                                                                  IV drug use                                                                                                                                                                                    Chest pain
                                                                                                                 FFaaeecacall  iinncoconnttiinneenncece                                                                                                                                                                                            Unremitting pain                                                                                                                                                                                                                                              Immune compromise                                                                                                                                                                              Haemoptysis
                                                                                                                 SaSaddddllee  aanneeststhheesisiaa                                                                                                                                                                                                Pain at multiple sites                                                                                                                                                                                                                                        Nausea and vomiting                                                                                                                                                                            Flank pain
                                                                                                                 AbAbnnoormarmall  nneeuurorollooggyy                                                                                                                                                                                              Unexplained weight loss                                                                                                                                                                                                                                                                                                                                                                                                                                      Hematuria
                                                                                                                                                                                                                                                                                                                                                   Pain worse at night / lying down                                                                                                                                                                                                                                                                                                                                                                                                                             Known AAA                                                                                                                                                                                                                                         EMERGENCY
                                                                                                               NNoonnee  ppreresesenntt                                                                                                                                                                                                              AnAnAny y y ooofff   ttthhheeesesese   ppprereresesesennnttt:::   HHHiiiggghhh   riririsk sk sk fffooor r r sisisigggnnniiificaficaficannnttt   pppaaattthhhooolllooogggy y y - - - SMOSMOSMO   rererevivivieeewww
                                                                                                  RELEVRELEVRELEVRELEVANT MEDICALANT MEDICALANT MEDICALANT MEDICAL HIST HIST HIST HISTORORORORYYYY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Nil relevant
                                                                                                               BaBack ck ppaaiinn  hhiiststoory:ry:
                                                                                                                 OOOstststeeeooopppooorororosisisis s s ///   ppprerereviviviooouuus s s ooostststeeeooopppooorororotttiiic c c fffrararactctctuuurereres:s:s:   
                                                                                                  MEDICAMEDICAMEDICAMEDICATION / TION / TION / TION / ALLERGIES                      ALLERGIES                      ALLERGIES                      ALLERGIES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Nil regular medications
                                                                                                             Anticoagulants:
                                                                                                             Steroids
                                                                                                               IImmummunnee  momodduullaattoors:rs:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               201	B	
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               7.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               7.
                                                                                                              NNNooo   knknknooowwwnnn   aaalllllleeergrgrgiiieeesss !!!                                                                                                     ALALALLLLERERERGGGIIIES:ES:ES:
                                                                                 Emergency Medicine/Orthopaedics/Radiology  Sept 2017 !                                                                                                                                                                                                                                                                                                                                                                                                       1
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         (PLACE PATIENT LABEL HERE)
                                                                                                                                                                                                                                                                                                                                                                                                                       SURNAME: ____________________________________    NHI: _____________
                                                                                                                                                                                                                                                                                                                                                                                                                       FIRST NAMES: ____________________________________________________
                                                                                                                        ✓                                                                         ✗                                                                                                                                                                                                                    Date of Birth: _______ /_______ /_______                           SEX: _____________
                                                                                                                                      = YES                                                                    = NO  
                                                                                         PREMORBID FUNCTIONALPREMORBID FUNCTIONALPREMORBID FUNCTIONALPREMORBID FUNCTIONALPREMORBID FUNCTIONALPREMORBID FUNCTIONALPREMORBID FUNCTIONAL ST ST ST ST ST ST STAAAAAAATUS & SOCIALTUS & SOCIALTUS & SOCIALTUS & SOCIALTUS & SOCIALTUS & SOCIALTUS & SOCIAL HIST HIST HIST HIST HIST HIST HISTORORORORORORORYYYYYYY
                                                                                              Independent:                                                                                                    Yes                                                         No                                                    Details:
                                                                                     Stairs at home:                                                                                                          Yes                                                         No
                                                                                                     Occupation:
                                                                                    Drugs / ETOH:
                                                                                         VIVIVIVIVIVITTTTTTAAAAAALLLLLL      SISISISISISIGGGGGGNNNNNNSSSSSS                                                                                                              BPBP              ____________________________    mmHmmHgg                                                                                                                                                                                     RReesspp  RRaatete  _________    _________  minmin                                                                                                                                            PaPaiinn  ssccoorree    ______  /10____  /10
                                                                                                                      WWWWWWiiiiiitttttthhhhhhiiiiiinnnnnn      nnnnnnoooooormarmarmarmarmarmallllll      lllllliiiiiimimimimimimittttttssssss                           PuPullssee  ______________  bpm  ______________  bpm                                                                                                                                                                                           SPOSPO22  ______________   ______________  % %
                                                                                                                                                                                                                                                                         TeTemmpp  ______________    ______________  ℃℃                                                                                                                                                                                                               A A A Aiiiirrrr                               NP   NP   NP   NP                                       HHHHuuuuddddssssoooonnnn: : : : ________________    llll////mmmmiiiinnnn
                                                                                 GENERAL                                                                                                                                NNNOOOTTT   dddiiistststrereressessesseddd                                                                                     DDDiiistststrereressessesseddd:::
                                                                                 PAIN                                                                                                                               None  None                                                                                                                    Mild                                                                                  Moderate                                                                                          Severe
                                                                                         EXAMINAEXAMINAEXAMINAEXAMINAEXAMINAEXAMINAEXAMINAEXAMINATION    TION    TION    TION    TION    TION    TION    TION    
                                                                                 CVS                                                                                                                                    WWaarm rm aanndd  wweellll  ppeerfrfuusesedd
                                                                                                                                                     Pulses                                                           Normal
                                                                                                                                                            S1S2                                                      Normal
                                                   MEDICINE NOTES                RESPIRATORY
                                                                                                                                            Air entry                                                                 Normal
                                                                                                         Breath sounds                                                                                                Vesicular
                                                                                                          Added sounds                                                                                                No                                                           Yes:
                                                                                 ABDOMEN
                                                  EMERGENCY                                                           Appearance                                                                                      Not distended                                                                                                                 Distended  
                                                                                                                                      Palpation                                                                       Soft  
                                                                                                         Pulsatile mass                                                                                               No                                                           Yes                                            ? AAA
                                                                                                  Acute abdomen                                                                                                       No                                                           Yes                                            e.g guarding or rebound tendernesse.g guarding or rebound tendernesse.g guarding or rebound tenderness
                                                                                 Renal angle tender                                                                                                                   No                                                           Yes                                            ? Pyelonephritis
                                                                                            Bladder palpable                                                                                                          No                                                           Yes                                            ? Cauda equina
                                                                                            Post void volume                                                                                             _________   ml                                                                                                           If concerned ? Cauda EquinaIf concerned ? Cauda EquinaIf concerned ? Cauda EquinaIf concerned ? Cauda EquinaIf concerned ? Cauda EquinaIf concerned ? Cauda Equina!!!!!!. . . . . . More than 100 ml is  potentially significant - Senior reviewMore than 100 ml is  potentially significant - Senior reviewMore than 100 ml is  potentially significant - Senior reviewMore than 100 ml is  potentially significant - Senior reviewMore than 100 ml is  potentially significant - Senior reviewMore than 100 ml is  potentially significant - Senior review
                                                                                 OTHER
                                                                        Emergency Medicine/Orthopaedics/Radiology  Sept 2017 !                                                                                                                                                                                                                                                                                                                                                        2
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         (PLACE PATIENT LABEL HERE)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        SURNAME: ____________________________________    NHI: _____________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        FIRST NAMES: ____________________________________________________
                                                                                                                                                                                          ✓                                                                                                                  ✗                                                                                                                                                                                                                                                                                                                                          Date of Birth: _______ /_______ /_______                           SEX: _____________
                                                                                                                                                                                                               = YES                                                                                                             = NO  
                                                                                                                             PERIPHERALPERIPHERALPERIPHERALPERIPHERALPERIPHERALPERIPHERALPERIPHERALPERIPHERALPERIPHERAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL                           Abnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done alreadyAbnormal neurology is an indication for plain film imaging, if not done already         
                                                                                                                             POWER                                                                                                                                                                                                                                                                                                                                                 Right                                                                                                        Left       
                                                                                                                                                                                                                                                                            Hip Flexion                                                                                                                            L2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              OOxfxfoordrd  scascallee
                                                                                                                                                                                                                                    Knee Extension                                                                                                                                                                 L3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          0                                            No voluntary contraction
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               1                                            Flicker - no movement
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2                                            Movement if gravity eliminated
                                                                                                                                                                                                                    Ankle dorsiflexion                                                                                                                                                                              L4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          3                                            Movement against gravity
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               4                                            Movement against some resistance
                                                                                                                                                                                                  Great toe extension                                                                                                                                                                                              L5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          5                                            Normal muscle strength
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         NT                                                 Not testable (e.g due to severe pain)
                                                                                                                                       Ankle eversion/plantar flex                                                                                                                                                                                                                                                 S1
                                                                                                                                                                                                                                                                                Toe flexion                                                                                                                        S2
                                                                                                                             SENSATION                                                                                                                                                                                                                                                                                               NNNNoooormarmarmarmallll    iiiinnnn    aaaallllllll    ddddeeeermarmarmarmattttoooomemememessss
                                                                                                                             IIIIIIffffff      aaaaaabbbbbbnnnnnnoooooormarmarmarmarmarmallllll::::::      mark abnormal areas on the diagram on the right, and comment on :mark abnormal areas on the diagram on the right, and comment on :mark abnormal areas on the diagram on the right, and comment on :mark abnormal areas on the diagram on the right, and comment on :mark abnormal areas on the diagram on the right, and comment on :mark abnormal areas on the diagram on the right, and comment on :
                                                                                                                                                                                2 point discrimination                                                                                                                                                                                                                         Normal or:  Normal or:  Normal or:
                                                                                                                             REFLEXES
                                                                                                                                                                                                    0                            Absent
                                                                                                                                                                                                       -                         Reduced
                                                                                                                                                                                                  +                              Normal
                                                                                                                                                                                         ++                                      Brisk 
                                                                                                                                                                               +++                                               Pathological                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     MEDICINE NOTES
                                                                                                                                                                                                                                                Plantar reflex:                                                                                                                                           ↓↓↓         ↑↑↑                           ↓↓↓      ↑↑↑                     
                                                                                                                                                                                                                                                                                                                          Tone:                                                                          - - -          + + +                         - - -       + + +    
                                                                                                                             PR EXAMINATION                                                                                                                                                                                                                                                                                        NNNooottt   pppeeerfrfrfooormermermeddd
                                                                                                                                                                                                                                                                         Indications:                                                                                                              •••••••••                Saddle anesthesiaSaddle anesthesiaSaddle anesthesiaSaddle anesthesiaSaddle anesthesiaSaddle anesthesiaSaddle anesthesiaSaddle anesthesiaSaddle anesthesia
                                                                                                                                                                                                                                                                                                                                                                                                   •••••••••                Any abnormal neurologyAny abnormal neurologyAny abnormal neurologyAny abnormal neurologyAny abnormal neurologyAny abnormal neurologyAny abnormal neurologyAny abnormal neurologyAny abnormal neurology
                                                                                                                                                                                                                                                                                                                                                                                                   •••••••••                ? Cauda equina ? Cauda equina ? Cauda equina ? Cauda equina ? Cauda equina ? Cauda equina ? Cauda equina ? Cauda equina ? Cauda equina 
                                                                                                                                                                                                                                                                                                                                                                                                   •••••••••                Presence of any red flagsPresence of any red flagsPresence of any red flagsPresence of any red flagsPresence of any red flagsPresence of any red flagsPresence of any red flagsPresence of any red flagsPresence of any red flags                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             EMERGENCY
                                                                                                                                                                                                       Perianal sensation                                                                                                                                                                                                        NNoormarmall
                                                                                                                                                                                                                                                                      Rectal tone                                                                                                                                                NNoormarmall
                                                                                                                                                                                                                       Performed by Dr:
                                                                                                                             BBBAAACCCKKK   EXAEXAEXAMIMIMINNNAAATTTIIIOOONNN   &&&   MOMOMOBBBIIILLLIIITTTYYY            
                                                                                                                                                                                                                          Skin / soft tissue                                                                                                                                                                                     NNoormarmall                                                                                                                   ? Vesicles / blisters: ? Varicella Zoster? Vesicles / blisters: ? Varicella Zoster? Vesicles / blisters: ? Varicella Zoster
                                                                                                                                                                                                                      Bony tenderness                                                                                                                                                                                          None  None                                                                                                                    Percussion & palpationPercussion & palpationPercussion & palpation
                                                                                                                                                                                                                    Range of motion:
                                                                                                                                                                                                                Straight leg raise:
                                                                                                                                                                                                                           Femoral stretch:
                                                                                                                                                                                                                                                                 Gait:
                                                                                                                                                                                                                                              P P P P P P P P P - - - - - - - - - PaPaPaPaPaPaPaPaPaiiiiiiiiinnnnnnnnn       T       T       T       T       T       T       T       T       T         - - - - - - - - - TTTTTTTTTeeeeeeeeennnnnnnnndddddddddeeeeeeeeernrnrnrnrnrnrnrnrneeeeeeeeess ss ss ss ss ss ss ss ss                                                       C C C C C C C C C - - - - - - - - - CCCCCCCCCooooooooonnnnnnnnntttttttttuuuuuuuuusisisisisisisisisiooooooooonnnnnnnnn                                                               S S S S S S S S S - - - - - - - - - SkiSkiSkiSkiSkiSkiSkiSkiSkinnnnnnnnn         ttttttttteeeeeeeeeaaaaaaaaar r r r r r r r r                                                       A A A A A A A A A  - - - - - - - - - AbAbAbAbAbAbAbAbAbrararararararararasisisisisisisisisiooooooooonnnnnnnnn                                                               L L L L L L L L L - - - - - - - - - LLLLLLLLLaaaaaaaaacececececececececerararararararararatttttttttiiiiiiiiiooooooooonnnnnnnnn       Ce       Ce       Ce       Ce       Ce       Ce       Ce       Ce       Ce         - - - - - - - - - CCCCCCCCCeeeeeeeeelllllllllllllllllluuuuuuuuullllllllliiiiiiiiitttttttttiiiiiiiiis s s s s s s s s          
                                                                                                                Emergency Medicine/Orthopaedics/Radiology  Sept 2017 !                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    3
                                                                                                                                                   (PLACE PATIENT LABEL HERE)
                                                                                                                   SURNAME: ____________________________________    NHI: _____________
                                                                                                                   FIRST NAMES: ____________________________________________________
                                  ✓                    ✗                                                           Date of Birth: _______ /_______ /_______                           SEX: _____________
                                       = YES                = NO  
                              RADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGYRADIOLOGY               Indications Best Care Bundle pathway : Plain films page 1. MRI page 3Indications Best Care Bundle pathway : Plain films page 1. MRI page 3Indications Best Care Bundle pathway : Plain films page 1. MRI page 3Indications Best Care Bundle pathway : Plain films page 1. MRI page 3Indications Best Care Bundle pathway : Plain films page 1. MRI page 3
                                      Spine X-Ray:                     Normal
                                           Fractures:                  None
                                     PathologicalPathological          None
                                               lesions: lesions:                                                                                               FFiillms ms rerevivieewweedd  bby:y:  DDr r         ____________________________________
                           HHAAEMAEMATTOOLLOOGGYY                                                                   BBBBBBIIIIIIOOOOOOCCCCCCHHHHHHEMIEMIEMIEMIEMIEMISTSTSTSTSTSTRRRRRRYYYYYY                             URINEURINE
                       Hb                                              +                                    CRP                                                                                         WCC
                                                                  Na
                       WCC                                          +                                       β-HCG                                                                                       RCC
                                                                  K
                       PL                                         Gluc                                      INR                                                                                         Epi
                                                                  Creat                                     ALP                                                                                         Bacteria
                                                                         +
                                                                  Ca2
                                                                                                                                                             +
                      ↑Inflammatory markers: ? discitis / epidural abscess / osteomyelitis.  ↑ Ca2   or ALP think malignancy.  Discuss with SMO 
                              CLINICALCLINICALCLINICALCLINICALCLINICAL IMPRESSION / DIAGNOSIS / PLAN              IMPRESSION / DIAGNOSIS / PLAN              IMPRESSION / DIAGNOSIS / PLAN              IMPRESSION / DIAGNOSIS / PLAN              IMPRESSION / DIAGNOSIS / PLAN             
                       DIAGNOSIS:                                                  LLiikekelly y sisimpmpllee  memechchaanniicacall  lloowweer r bbaack ck ppaaiinn                          
                              Signs of Cauda Equina                              None  or                    Describe:
                            Signs of  spinal infection                           None  or                    Describe:
                                                                                 Other:
                       PLAN
               MEDICINE NOTES
              EMERGENCY
                                    Allied health review:                         Physiotherapy                                        NSH 931905                                       Mon-Fri 8am-3pm   Sa/Su 8am-1pmMon-Fri 8am-3pm   Sa/Su 8am-1pm
                                                                                  only if benefit likely                                WTH 021 854 358 / 931659                         Mon-Fri 8am-4pm  Mon-Fri 8am-4pm  
                       DISPOSITION                                           Refer to page 2 and 3 for disposition decision guidance. Refer to page 2 and 3 for disposition decision guidance. Refer to page 2 and 3 for disposition decision guidance. Refer to page 2 and 3 for disposition decision guidance.  Interdepartmental agreement Interdepartmental agreement Interdepartmental agreement Interdepartmental agreement
                                       Discharge                                 Admit Ortho                                                   AdAdmimitt  GGeenn  MeMedd                                    Admit AT&R 
                          Clinician Name:                                             Designation:                  Sign:                         Contact details:  _________
                          For junior staff:                             Discussed with                             Reviewed by    SMO: ______________________________________
                     Emergency Medicine/Orthopaedics/Radiology  Sept 2017 !                                                          4