Appendix 4

Documentation, handover, and quality assurance

Structure of an emergency case record

Record section	Minimum content
Identification and timing	Patient, arrival date and time, triage, assessments, consultations, decision to intervene, transfer.
Initial information	Presenting symptoms, symptom onset, history, allergies, medications, anticoagulants, pregnancy, devices, and associated risks.
Assessment	Vital signs, physical examination, laboratory and imaging results, working diagnosis, and differential diagnosis.
Decision	Rationale for management, alternatives, discussion with relevant specialists, consent/refusal or grounds for emergency intervention.
Actions taken	Drugs, infusions, procedures, times, operator, technical outcome, complications, and patient response.
Plan	Monitoring, escalation criteria, further treatment, transfer, device follow-up, and responsibility for pending results.

Register of catheters, stents, nephrostomies, and drains

Register field	Contents
Patient and device	Patient identifier, device type, side, and location.
Insertion	Date and time, indication, operator, model/size if available, and fixation method.
Monitoring	Patency, output, exit-site condition, complications, and investigation results.
Plan	Date and location of the next review, replacement, or removal; responsible specialist and unit.
Patient education	Care, restrictions, signs of complications, and emergency contact details.
Closing the record	Actual replacement/removal date or transfer of responsibility to another organization.

Pending results and follow-up

include every result expected after discharge or transfer in a separate tracking list;
for each result, specify the responsible specialist, expected reporting time, means of contacting the patient, and action for an abnormal finding;
document review of the result, the decision made, and contact with the patient;
if the patient cannot be contacted, follow local procedures and record all attempts.

Internal quality indicators

Area	Indicator
Referral and transfer pathways	Time to consultation and transfer; proportion of transfers with complete documentation; reasons for delays.
Documentation	Proportion of records containing required timestamps, device details, consent/refusal, and a follow-up plan.
Devices	Proportion of devices with a scheduled review date; number of overdue devices; unplanned occlusions and reattendance.
Investigation results	Proportion of results reviewed by the responsible person within the locally specified period; proportion of successful patient contacts.
Safety	Complications, repeat interventions, readmissions, adverse events, and completed corrective actions.
Updating	Date of the latest review of the regulatory framework, formulary, antibiogram, and guide version.