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INCLUDE ONLY ITEMS RELEVANT TO THE INJURY/ILLNESS
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Method of Communication
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Site or Vessel Name
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Information Reviewed with Patient
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Comments/other interaction (free text)
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Provider or Case Manager Name
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Additional Person(s) Spoken to (free text)
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Employer(if applicable)
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Occupation (if applicable)
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GCC Medical Specialist (RMI Call center)
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Case Number (if relevant)
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RMI Topside Physician(s) Consulted (select all that apply)
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Patient Assessment
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Have you updated Body System Involved in the SUBJECTIVE section? Yes / No ------->
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Date & Time of Symptoms
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Date & Time of Incident (if relevant)
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History of Present Injury/Illness Summary (focused)
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Relevant Past Medical History
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Relevant Allergies
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Is today's visit a Pre-existing condition?
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If a Pre-Existing Condition, explain:
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Physical Exam (Brief Description of Relevant Exam)
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Testing
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Point of Care (POC) Testing
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POC Results/notes
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ECG Reading
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Current Suspected Diagnosis
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Diagnosis (free text)
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Treatment and Disposition
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Medical Decision Making (document your thought process)
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Employer Can Accommodate the Patients Condition Yes / No
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Treatment/Clinic Course (Free text)
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Oral Meds Given & Consumed During Visit:
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Discharge Plan
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Injury Treatment Instructions
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Plan of Care Details
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Evacuation or Referral Offsite is being Recommended: Yes / No
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Preferred Destination of Evacuation/Referral
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Additional Details of Evacuation
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Notifications
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Safety/Management Notified
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Name: Safety/Management notified
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Is Follow Up Required:
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Date of Planned Follow up
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Work Status Details
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Work/Duty Status
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Restricted Work Case
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Work Restriction Type:
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Date when Work Restriction Started
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Date when Work Restriction Ended
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Date when Lost Time Started
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Lost Time (LTI) Day Count
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