NSW Ambulance electronic Medical Record (eMR version 2.3.1)
Data Request Form
October 2015
Dear Researcher
NSW Ambulance datasets
NSW Ambulance routinely collects operational and clinical data. Operational data are captured in the Computer Aided Dispatch (CAD) system. The paperbased Patient Health Care Record (PHCR) and electronic Medical Record (eMR) are NSW Ambulance’s principal clinical datasets.
This document lists the research-related variables captured in eMR that may be requested for research purposes. Brief descriptions and possible predefined
values of these data elements are provided.


Operational information
o
CAD is a centralised state-wide emergency and patient transport call-taking and dispatch system that utilises VisiCAD software for the
logging and allocation of resources to Triple Zero (000) calls.
o
It has an integrated mapping component that displays vehicle and incident information in real time and utilises GPS tracking of all frontline
ambulances to assist in the dispatch process.
o
CAD records are available from July 2000.
Clinical information
o
Data collected during the patient care episode are recorded by paramedics in either the PHCR or eMR. This includes information about the
incident (e.g. reason for call and scene location), patient information (e.g. demographics, injury/illness characterisation, vital signs and
assessment results), treatment details (e.g. pharmacology and interventions), and outcomes (e.g. transported, not transported, died).
o
Paramedics complete a clinical record for all incidents including inter-hospital/facility transfers. Clinical records are required, even if there is
no patient contact, for all road traffic incidents, for incidents where the patient cannot be found or has left the scene, or where services are
not required. Cases where a patient is already deceased prior to paramedics’ arrival are also documented.
o
Since its staged introduction in 2011, the eMR is the preferred clinical record.
o
The PHCR is completed by paramedics only in the absence of an eMR. At the time of writing, Extended Care Paramedics, volunteers and
single responders only use the PHCR. The PHCR is also used in some regional areas.
o
Unlike the PHCR, the eMR directs compulsory completion of some screens/fields.
o
PHCR data are available from April 2001 and eMR data are available from 2011.
NSW Ambulance eMR Data Request Form
i
This document lists research-related fields recorded in the eMR.
Please enter your research question/s and the relevant date range/s in the table below. On subsequent pages, indicate the variables required to:


Identify cases of interest (inclusion/exclusion criteria) - e.g. determining included cases by ‘case nature’.
Address the research question.
Please also briefly outline how each variable directly relates to the stated research question/s.
CAD and PHCR data requests should be lodged separately if required.
Please note that data extraction is associated with a cost to NSW Ambulance. These costs may be passed on to the researcher. Costs are determined by the
extent of work that is necessary to satisfy the request.
Data will not be provided for non-specific enquiry.
Please direct queries to:
E: research@ambulance.nsw.gov.au
P: 02 9779 3865
Date range/s of interest
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Research question/s
1
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2
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3
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NSW Ambulance eMR Data Request Form
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In all Tables, yellow shading denotes data fields that are mandatory for paramedics to complete.
Description
Required? 
Justification for this request
Crew
Fleet unit #
Vehicle number and division
☐
Click here to enter text.
Unit skill set
The highest clinical level of the crew
☐
Click here to enter text.
Case number (EPCIRD)
Unique eMR incident number
☐
Click here to enter text.
Date
Date of incident
☐
Click here to enter text.
Case given as
Suspected patient problem, e.g. ‘fall’
☐
Click here to enter text.
☐
Click here to enter text.
Priority – e.g. ‘lights & sirens’ emergency or urgent
☐
Click here to enter text.
Location type
E.g. residence, hospital
☐
Click here to enter text.
Common location
List of high frequency locations specific to an area
☐
Location name
E.g. Residential Aged Care Facilities
☐
Street
Full street information
☐
Click here to enter text.
Suburb
Suburb - postcode auto pop
☐
Click here to enter text.
State
E.g., NSW, Victoria
☐
Click here to enter text.
Case
Odom start (km)
Dispatch code
Scene
NSW Ambulance eMR Data Request Form
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1
Description
Required? 
Justification for this request
Patient
The patient’s sex: male/female
Full date of birth will only be supplied if sufficient justification
is supplied that age is insufficient.
Best estimate or actual
☐
Click here to enter text.
☐
Click here to enter text.
☐
Click here to enter text.
As scene
May be same as scene address
☐
Click here to enter text.
Location name
Landmarks only, including Residential Aged Care Facilities
☐
Street
The patient’s street name
☐
Click here to enter text.
Suburb
The patient’s suburb
☐
Click here to enter text.
State
The state in which the scene is located, e.g., NSW, Victoria
☐
Click here to enter text.
Gender
Date of birth
Age
Address (patient)
NSW Ambulance eMR Data Request Form
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2
Past history
Pre-existing conditions
Select from REFERENCE TABLE 1, pages 4 and 5
Required?
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Justification for this request:
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Allergies
Justification for this request:
Click here to enter text.
Click here to enter text.
Indicate required fields:
No Known Allergies ☐
Local Anaesthetic ☐
Unknown Allergies ☐
Mannitol ☐
Adhesive Tape / Dressing ☐
Metaraminol Bitartrate ☐
Adrenaline Tartrate ☐
Methoxyflurane ☐
Amiodarone ☐
Metoclopramide ☐
Antibiotic ☐
Midazolam ☐
Aspirin ☐
Milk Products ☐
Atracurium ☐
Morphine Sulphate ☐
Atropine Sulphate ☐
Naloxone Hydrochloride ☐
Bee / Wasp / Ant Sting ☐
Nifedipine ☐
Benztropine ☐
NSAIDs ☐
Birds / Feathers ☐
Nuts / Seeds ☐
Box Jellyfish Antivenom ☐
Ondansetron ☐
Chlorhexidine ☐
Other ☐
Chocolate ☐
Pancuronium Bromide ☐
Codeine or Prescribed Opiates ☐
Paracetamol ☐
Dextrose ☐
Parecoxib Sodium ☐
Diazepam ☐
Pet Hair ☐
Dobutamine ☐
Pethidine Hydrochloride ☐
Dopamine ☐
Prochlorperazine ☐
Drixine ☐
Promethazine ☐
Eggs ☐
Propofol ☐
Entonox ☐
Rocuronium ☐
Fentanyl ☐
Salbutamol ☐
Fruit / Vegetable ☐
Seafood ☐
Frusemide ☐
Sodium Bicarbonate ☐
Glucagon ☐
Steroid ☐
Gluten ☐
Suxamethonium Chloride ☐
Glyceryl Trinitrate ☐
Tirofiban ☐
Grass / Pollen ☐
Tramadol ☐
Haloperidol ☐
Vaccine ☐
Hartmanns ☐
Vecuronium ☐
Heparin ☐
Verapamil Hydrochloride ☐
Iodine / Betadine ☐
Vinegar ☐
Ipratropium Bromide ☐
Virkon ☐
Latex ☐
Wheat ☐
Lignocaine Hydrochloride ☐
X-Ray Contrast ☐
Zinc ☐
NSW Ambulance eMR Data Request Form
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REFERENCE TABLE 1: Pre-existing conditions (continued on page 5)
Nil Known ☐
Atrial Fibrillation ☐
Cardiomyopathy ☐
Deep Vein Thrombosis ☐
Gallstones ☐
Unknown ☐
Atrial Flutter ☐
Carotid Endarterectomy ☐
Dementia ☐
Gastric Reflux ☐
Abdominal Aortic Aneurysm ☐
Abdominal Aortic Aneurysm ☐
Repair ☐
Abdominal Pain ☐
Autonomic Dysreflexia ☐
Carotid Stenosis ☐
Depression ☐
Glaucoma ☐
Back Pain ☐
Cataract/s ☐
Diabetes ☐
Gout ☐
Back Problems ☐
Cataract Surgery ☐
Dialysis ☐
Grommets ☐
Acquired Brain Injury ☐
Back Surgery ☐
Cellulitis ☐
Diarrhoea ☐
Haematemesis ☐
Acute Myocardial Infarction ☐
Bipolar Disorder ☐
Cerebral Aneurysm ☐
Dislocation ☐
Haematuria ☐
Angiogram ☐
Bladder Cancer ☐
Cerebral Haemorrhage ☐
Diverticular Disease ☐
Haemoptysis ☐
Acute Pulmonary Oedema ☐
Bleeding Disorder ☐
Cerebral Palsy ☐
Down's Syndrome ☐
Haemorrhoids ☐
AIDS ☐
Bleeding in Pregnancy ☐
Chest Infection ☐
Drug Abuse ☐
Hallucinations ☐
Alcohol Abuse ☐
Bleeding - Other /Not Listed ☐
Chest Pain ☐
Drug Overdose ☐
Headache ☐
Alcohol Overdose ☐
Bone Cancer ☐
Ear Infection ☐
Hearing Loss ☐
Alzheimer's Disease ☐
Bowel Cancer ☐
Eating Disorder ☐
Heart Transplant ☐
Amputation ☐
Bowel Obstruction ☐
Cholecystectomy ☐
Chronic Obstructive Pulmonary
Disease ☐
Cirrhosis ☐
Ectopic Pregnancy ☐
Heart Valve Problem ☐
Anaemia ☐
Bowel Resection ☐
Coeliac Disease ☐
Emphysema ☐
Heart Valve Repair ☐
Anaphylaxis ☐
Bradycardia ☐
Colostomy / Ileostomy ☐
Encephalitis ☐
Hemiparesis ☐
Angina ☐
Brain Surgery ☐
Congenital Heart Defect ☐
Endometriosis ☐
Hemiplegia ☐
Angioedema ☐
Brain Tumour / Cancer ☐
Hernia ☐
Breast Cancer ☐
Constipation ☐
Corneal Transplant
ENT Problem ☐
Anxiety ☐
Epiglottitis ☐
Hepatitis A ☐
Appendicectomy ☐
Bronchiolitis ☐
Coronary Artery Graft Surgery ☐
Epistaxis ☐
Hepatitis B ☐
Arm Pain ☐
Bronchitis ☐
Coronary Angioplasty/ Stent ☐
Eye Injury / Problem ☐
Hepatitis C ☐
Arrhythmia-Other/Not Listed ☐
Bundle Branch Block ☐
Cough ☐
Fainting Episodes ☐
Hip Joint Replacement/ Repair ☐
Arthritis – Osteo ☐
Burn/s ☐
Cramps ☐
Falls ☐
HIV Positive ☐
Arthritis – Rheumatoid ☐
Cancer - Other / Not Listed ☐
Crohn's Disease ☐
Femoropopliteal Bypass ☐
Hydrocephalus ☐
Ascites ☐
Cardiac Arrest ☐
Croup ☐
Fracture - Neck of Femur ☐
Asthma ☐
Cardiac Failure ☐
Cystic Fibrosis ☐
Fracture - Other ☐
NSW Ambulance eMR Data Request Form
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REFERENCE TABLE 1 continued: Pre-existing conditions
Hypercholesterolaemia ☐
Lung Surgery
Pancreatic Cancer ☐
Renal Calculi / Colic ☐
Throat Infection ☐
Hyperlipidaemia ☐
Lung Transplant ☐
Pancreatitis ☐
Renal Failure ☐
Thrombolysis (Cardiac) ☐
Hypertension ☐
Lymphoedema ☐
Panic Attack ☐
Respiratory Arrest ☐
Thrombolysis (Cerebral) ☐
Hyperthyroidism ☐
Malignant Hyperthermia ☐
Paraplegia ☐
Respiratory Tract Infection ☐
Thrombolysis (Other) ☐
Hypotension ☐
Melaena ☐
Parkinson's Disease ☐
Rhinoplasty ☐
Thyroid Surgery ☐
Hypothyroidism ☐
Meningitis ☐
Peg Tube ☐
Schizophrenia ☐
Tonsillectomy ☐
Hysterectomy ☐
Menstrual Disorder ☐
Pericarditis ☐
Seizure/s / Convulsion/s ☐
Tracheostomy ☐
Incontinence - Faecal ☐
Migraine/s ☐
Peripheral Vascular Dis. ☐
Self Harm Attempt ☐
Transient Ischaemic Attack ☐
Incontinence - Urinary ☐
Infectious Disease - Other / Not
Listed ☐
Influenza Illness ☐
Motor Neurone Disease ☐
Personality Disorder ☐
Self Harm Thoughts ☐
Tremor ☐
Multiple Sclerosis ☐
Plastic Surgery ☐
Sepsis ☐
TURP ☐
Myasthenia Gravis ☐
Pleural Effusion ☐
Septicaemia ☐
Ulcer ☐
Injecting Drug Use ☐
Nausea ☐
Pneumonia ☐
Shingles ☐
Ulcerative Colitis ☐
Intellectual Impairment ☐
Neck Injury ☐
Pneumothorax ☐
Shoulder / Clavicle Repair ☐
Urinary Catheter ☐
Internal Defibrillator ☐
Neck Pain ☐
Post Natal Depression ☐
Skin Cancer ☐
Urinary Tract Infection ☐
Irritable Bowel ☐
Nephrectomy ☐
Post Partum Haemorrhage ☐
Skin Problems ☐
Urine Retention ☐
Ischaemic Heart Disease ☐
Obesity ☐
Pre-Eclampsia ☐
Sleep Apnoea ☐
Vaccination / Immunisation ☐
Kidney Transplant ☐
Oesophageal Varices ☐
Spasm/s ☐
Vaginal Bleeding ☐
Knee Replacement / Repair ☐
Oesophagitis ☐
Spina Bifida ☐
Varicose Veins ☐
Laminectomy ☐
Osteoporosis ☐
Pregnancy ☐
Pregnancy Induced ☐
Hypertension ☐
Prostate Cancer ☐
Spinal Fusion ☐
Ventricular Shunt ☐
Leg Pain ☐
Other - Specify ☐
Prostate Problem ☐
Spinal Injury ☐
Ventricular Tachycardia ☐
Leukaemia ☐
Ovarian Cancer ☐
Post-Traumatic Stress Dis. ☐
Splenectomy ☐
Vertigo ☐
Liver Cancer ☐
Ovarian Cyst ☐
Psychiatric Problem ☐
Spontaneous Abortion ☐
Violent Behaviour ☐
Liver Disease ☐
Pacemaker - Permanent ☐
Pulmonary Embolus ☐
Stroke ☐
Vision Impairment ☐
Liver Failure ☐
Pacemaker - Temporary ☐
Pyrexia (Unknown Origin) ☐
Supraventricular Tachycardia ☐
Weight Loss ☐
Liver Transplant ☐
Pain - Other / Not Listed ☐
Quadriplegia ☐
Systemic Lupus Erythematosus ☐
Wound Infection ☐
Lung Cancer ☐
Palpitations ☐
Rectal Bleeding ☐
Surgery - Other / Not Listed ☐
NSW Ambulance eMR Data Request Form
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Description
Justification for this request
Current medications
Captures any recorded medications
Risk factors
As below:
Click here to enter text.
Indicate required fields:
Nil Known
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NSW Ambulance eMR Data Request Form
Age
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Alcohol Abuse
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Diabetes
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Drug Abuse
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Family History
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Hypercholesterolaemia
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Hypertension
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Infectious Disease Risk
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Obesity
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Occupational
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Other - Specify
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Smoker
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Unknown
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6
Case History
Case nature
Justification for this request:
Indicate required fields:
Paramedic determined main problems
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Nil Problem ☐
Foreign Body ☐
Unknown Problem ☐
Gastrointestinal Problem ☐
Alcohol Requesting Detox ☐
Genitourinary Problem ☐
Alcohol Withdrawal ☐
Hanging ☐
Allergy ☐
Immune Problem ☐
Animal Related Injury - Other ☐
Inhalation ☐
Assault ☐
Lightning Strike ☐
Bicycle Collision ☐
Medical - General ☐
Biological Exposure ☐
Motorcycle Collision ☐
Bite / Sting / Envenomation ☐
Motor Vehicle Collision ☐
Cardiovascular Problem ☐
Musculoskeletal Problem ☐
Chemical Exposure ☐
Neurological Problem ☐
Crush ☐
Obstetrics / Gynaecology Problem ☐
Dermatology Problem ☐
Oncology Problem ☐
Drowning / Immersion ☐
Other - Specify ☐
Drug Requesting Detox ☐
Overdose / Exposure ☐
Drug Withdrawal ☐
Pedestrian Collision ☐
Electrical Contact ☐
Psychiatric Problem ☐
Emotional Problem ☐
Radiation Contamination ☐
Endocrine Problem ☐
Respiratory Problem ☐
ENT Problem ☐
Shooting ☐
Environmental Exposure ☐
Social Situation Problem ☐
Explosion / Incendiary Device ☐
Sporting Injury ☐
Eye Injury / Problem ☐
Stabbing ☐
Fall ☐
Struck By Object ☐
Fire / Smoke Exposure ☐
Surgical - General ☐
Case description
Free text description of case-related events
Required? 
☐
Justification for this request:
Click here to enter text.
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NSW Ambulance eMR Data Request Form
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Description
On arrival
Scene findings
Justification for this request:
Dangers, patient position, social situation, ethnicity
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Others at scene
All others at scene on arrival (e.g. Police, family, GP)
Required? 
☐
Justification for this request:
Prior care management
Justification for this request:
Indicate required fields:
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Activities occurring prior to paramedic arrival
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Unknown ☐
Airway Management ☐
Cervical Collar/Spine Immobilisation ☐
Chest Compressions ☐
Compression Bandage ☐
Cooling ☐
Defibrillation Prior to Ambulance ☐
ECG ☐
Expired Air Resuscitation ☐
Haemorrhage Control ☐
Heat Pack ☐
Massage / Stretching ☐
Medication ☐
No Prior Care ☐
Oxygen Therapy ☐
Position ☐
RICE ☐
Splint / Sling ☐
Ventilation – Manual ☐
Witnessed Arrest ☐
Other - Specify ☐
NSW Ambulance eMR Data Request Form
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Patient complaint
Indicate required fields
Justification for this request:
Nil Complaint Reported ☐
Depression ☐
Hallucinations ☐
Neck Stiffness ☐
Suicidal ☐
Unknown Problem ☐
Diarrhoea ☐
Headache ☐
Noisy Breathing ☐
Suicide Attempt ☐
Agitation ☐
Difficulty Standing ☐
Heart Burn ☐
Not Speaking ☐
Swallowing Problems ☐
Alcohol / Drug Use ☐
Discharge ☐
Hiccups ☐
Obvious Death ☐
Sweating ☐
Alcohol Withdrawal ☐
Discomfort ☐
Hives ☐
Oliguria ☐
Swelling ☐
Altered Sensation ☐
Disoriented ☐
Hoarse Voice ☐
Other - Specify ☐
Swollen Glands ☐
Anxiety ☐
Distension ☐
Homeless ☐
Pain ☐
Swollen Joint ☐
Behavioural Change ☐
Dizzy ☐
Hunger ☐
Palpitations ☐
Swollen Limb ☐
Bite / Sting / Envenomation ☐
Domestic Conflict ☐
Hyperventilation ☐
Panic ☐
Tenderness ☐
Bleeding - Arterial ☐
Drooling ☐
Inadequate Resource for Care ☐
Requirement ☐
Post Partum Bleeding ☐
Thirst ☐
Bleeding - Venous ☐
Drowsy ☐
Incontinence ☐
PR Bleeding ☐
Tightness ☐
Bleeding - Other / Not Listed ☐
Drug Withdrawal ☐
Insomnia ☐
PV Bleeding ☐
Tinnitus / Ringing ☐
Bloating ☐
Dysmenorrhoea ☐
Itch ☐
Rapid Pulse ☐
Tired ☐
Body Fluid Contact ☐
Emotional Distress ☐
Jaundice ☐
Rash ☐
Toothache ☐
Breathing Problem / Difficulty ☐
Epistaxis ☐
Laceration ☐
Redness ☐
Tremor ☐
Bruising / Haematoma ☐
Facial Droop ☐
Lesion ☐
Respiratory Arrest - Suspected ☐
Unable to Self Care ☐
Burn/s ☐
Feeling Faint ☐
Light Headed ☐
Ruptured Membranes ☐
Unconscious ☐
Cardiac Arrest - Suspected ☐
Fainted ☐
Light Sensitivity ☐
Seizure/s / Convulsion/s ☐
Unwell ☐
Childbirth ☐
Feeling Cold ☐
Loss of Hearing ☐
Self Harm Thoughts ☐
Urine Flow / Frequency Problem ☐
Chills ☐
Feeling Hot ☐
Loss of Memory ☐
Shaking / Tremor ☐
Urine Retention ☐
Choking ☐
Fever ☐
Loss of Power ☐
Shivering ☐
Vertigo ☐
Collapse ☐
Flu - Like Symptoms ☐
Loss of Sensation ☐
Short of Breath ☐
Violent Behaviour ☐
Confusion ☐
Foreign Body ☐
Loss of Vision ☐
Skin Irritation ☐
Visual Disturbance / Loss ☐
Constipation ☐
Goose Bumps ☐
Loss Of Appetite ☐
Skin Lesion ☐
Vomiting ☐
Contractions ☐
Haematemesis ☐
Melaena ☐
Sore Throat ☐
Weakness ☐
Cough ☐
Haematuria ☐
Migraine/s ☐
Spasm/s ☐
Weight Loss ☐
Cramps ☐
Haemoptysis ☐
Movement Problem ☐
Speech Problem ☐
Wheeze ☐
Deformity ☐
Haemorrhoids ☐
Nausea ☐
Spinning Out ☐
NSW Ambulance eMR Data Request Form
9
Description
On examination
Primary Survey
The findings from a preliminary examination, which identifies potentially immediately life threatening issues.
Indicate required fields:
No immediate life threat
Airway ☐
Breathing ☐
Circulation ☐
Response ☐
Cervical spine ☐
Ventilation ☐
Haemorrhage check ☐
Justification for this request:
Secondary survey
Justification for this request:
Click here to enter text.
Click here to enter text.
The findings from ‘head to toe’ examination. Select from REFERENCE TABLE 2, page 11
Click here to enter text.
Click here to enter text.
Assessment
Initial assessment
Justification for this request:
Primary assessment
Justification for this request:
Secondary assessment
Justification for this request:
NSW Ambulance eMR Data Request Form
The patient’s main problem as determined by the paramedic. Select from REFERENCE TABLE 3, page 12.
Click here to enter text.
Click here to enter text.
Paramedics select only one as per RERERENCE TABLE 3, page 12. Please print second copy of TABLE 3 if required
‘Primary’ assessment variables differ from selected Initial Assessment fields.
Click here to enter text.
Click here to enter text.
Any secondary concerns – may be many or none. Select from REFERENCE TABLE 3, page 12. Please print another copy
of TABLE 3 if required Secondary Assessment variables differ from selected Initial or Primary Assessment fields.
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10
REFERENCE TABLE 2: Secondary Survey
No Abnormality Detected ☐
No Other Abnormalities
Detected ☐
Dislocation ☐
Itch ☐
Rash ☐
Distension ☐
Jaundice ☐
Redness ☐
Unknown / Not Assessed ☐
Dizzy ☐
Joint Stiffness ☐
Reduced Movement ☐
Abrasion / Graze ☐
Drooling ☐
Joint Warmth ☐
Retrograde Amnesia ☐
Altered Conscious State ☐
Drowsy ☐
Laceration ☐
Response - MSA ☐
Alcohol Involved ☐
Drug Paraphernalia Present ☐
Lacrimation / Tearing ☐
Rigidity ☐
Altered Sensation ☐
Dry Mucosa ☐
Lethargy ☐
Rigor Mortis ☐
Amputation ☐
Dysphagia ☐
Light Headed ☐
Seizure/s / Convulsion/s ☐
Anxiety ☐
Engorged Neck Veins ☐
Ligature Marks ☐
Shivering ☐
Aphasia ☐
Epistaxis ☐
Limb Rotation ☐
Short of Breath ☐
Appearance ☐
Erythema / Reddening ☐
Limb Shortening ☐
Skin - Localised ☐
Ascites ☐
Evisceration ☐
Limb Threatening Injury ☐
Skin Turgor ☐
Aspiration ☐
Extremity - Movement ☐
Loss Of Appetite ☐
Soot In Mouth / Airway ☐
Avulsion ☐
Extremity - Sensation ☐
Loss of Function ☐
Sore Throat ☐
Behaviour ☐
Extremity - Temperature ☐
Lump ☐
Spasm/s ☐
Bite Mark ☐
Eye Movement ☐
Mass ☐
Speech ☐
Bleeding - Arterial ☐
Facial Expression ☐
Melaena ☐
Sputum ☐
Bleeding - Venous ☐
Fatigue ☐
Mood ☐
Stiffness ☐
Bleeding -Other/Not Listed ☐
Fever ☐
Mottled Skin ☐
Sting Mark ☐
Blister(s) ☐
Flaccidity ☐
Mucosa ☐
Surgical Emphysema ☐
Breath ☐
Foreign Body ☐
Nausea ☐
Sweating ☐
Bruising / Haematoma ☐
Fracture/s ☐
Neatness ☐
Swelling ☐
Burn/s ☐
Groaning ☐
Neck Stiffness ☐
Swollen Glands ☐
Cataract/s ☐
Grunting ☐
Neck Veins ☐
Teeth Missing ☐
Cellulitis ☐
Guarding ☐
Necrosis ☐
Thirst ☐
Childbirth - Actual ☐
Haematemesis ☐
Neuro Facial Droop ☐
Thought ☐
Childbirth - Labour ☐
Haemoptysis ☐
Neuro Grips ☐
Tinnitus / Ringing ☐
Cleanliness ☐
Haemorrhoids ☐
Neuro Speech ☐
Trachea ☐
Concentration ☐
Headache ☐
Neurovascular ☐
Observations ☐
Tremor ☐
Constipation ☐
Hearing Loss ☐
Not Speaking ☐
Unconscious ☐
Cough ☐
Hemiplegia ☐
Nystagmus ☐
Unnatural Movement ☐
Cramps ☐
Hemiparesis ☐
Oedema ☐
Unsteady Gait ☐
Crepitus ☐
Hiccups ☐
Other ☐
Urinary Problems ☐
Crying / Tearful ☐
Hoarse Voice ☐
Pain ☐
Cyanosis ☐
Hyperventilation ☐
Palpitations ☐
Vertigo ☐
Visual Disturbance / Loss
Deformity ☐
Impaled ☐
Perceptions ☐
Vomiting ☐
Degloving ☐
Incontinence ☐
Weakness ☐
Diaphoretic ☐
Inflammation ☐
Photosensitivity ☐
Poor Short Term Memory
Diarrhoea ☐
Injection Marks ☐
Postmortem Lividity ☐
Discharge ☐
Insight ☐
Pregnancy ☐
Discolouration ☐
Irregularity ☐
Pulseless Limb ☐
NSW Ambulance eMR Data Request Form
☐
☐
Weight Bearing ☐
Wound / Puncture ☐
11
REFERENCE TABLE 3: Assessment
Primary assessment - paramedics select only one main condition
Secondary assessment – paramedics can select none or many secondary conditions
Final assessment - paramedics can select none or many
Revised assessment – main problem after examination
No Problem Identified
Select.
Constipation
Select.
Unknown Problem
Select.
Cough
Select.
Abdominal Aortic
Aneurysm
Select.
Cramps
Select.
Abdominal Distension
Select.
Croup
Select.
Abrasion / Graze
Select.
Deceased
Select.
Acute Coronary Syndrome
Select.
Decompression Illness
Select.
Acute Myocardial Infarction
Select.
Deep Vein Thrombosis
Select.
Acute Pulmonary Oedema
Select.
Dehydration
Select.
Airway Obstruction
Select.
Depression
Select.
Allergic Reaction
Select.
Diarrhoea
Select.
Altered Conscious State
Select.
Diplopia
Select.
Amputation
Select.
Dislocation
Select.
Anaphylaxis
Select.
Dizzy
Select.
Angina
Select.
Dysuria
Select.
Anxiety
Select.
Ear Problem
Select.
Aortic Dissection
Select.
Eating Disorder
Select.
Arrhythmia
Select.
Ectopic Pregnancy
Select.
Asthma
Select.
Emotional Distress
Select.
Asymptomatic
Select.
Epiglottitis
Select.
Avulsion
Select.
Epistaxis
Select.
Blister(s)
Select.
Eye Injury / Problem
Select.
Bowel Obstruction
Select.
Face Injury / Problem
Select.
Bronchiolitis
Select.
Faint
Select.
Bronchitis
Select.
Febrile
Select.
Bruising / Haematoma
Select.
Feed Tube Problem
Select.
Burn/s
Select.
Flail Chest
Select.
Cardiac Arrest
Select.
Fracture/s
Select.
Cardiac Failure
Select.
Gastrointestinal Problem
Select.
Cellulitis
Select.
Haematemesis
Select.
Chest Infection
Select.
Haematuria
Select.
Childbirth
Select.
Headache
Select.
Chronic Obstructive
Pulmonary Disease
Select.
Head Injury
Select.
Collapse
Select.
Hearing Loss
Select.
Compartment Syndrome
Select.
Heat Stress
Select.
Confusion
Select.
Heat Stroke
Select.
NSW Ambulance eMR Data Request Form
12
REFERENCE TABLE 3: Assessment
Primary assessment - paramedics select only one main condition
Secondary assessment – paramedics can select none or many secondary conditions
Final assessment - paramedics can select none or many
Revised assessment – main problem after examination
Hyperglycaemia
Select.
Renal Failure
Select.
Hypertension
Select.
Respiratory Arrest
Select.
Hyperventilation
Select.
Respiratory Failure
Select.
Hypoglycaemia
Select.
Respiratory Tract Infection
Select.
Hypotension
Select.
Seizure/s / Convulsion/s
Select.
Hypothermia
Select.
Sepsis
Select.
Implantable Defibrillator
Problem
Select.
Short of Breath
Select.
Incontinence - Faecal
Select.
Sleep Disorder
Select.
Incontinence - Urinary
Infection - Other / Not
Listed
Intracranial Haemorrhage
Select.
Social Problem
Select.
Select.
Soft Tissue Injury
Select.
Select.
Spasm/s
Select.
Joint Effusion
Select.
Spinal Cord Injury Suspected
Select.
Laceration
Select.
Strain / Sprain
Select.
Melaena
Meningococcal Septicaemia
(Possible)
Migraine/s
Select.
Stroke
Select.
Select.
Subarachnoid Haemorrhage
Select.
Select.
Sunburn
Select.
Mobility Problem
Select.
Surgical Emphysema
Select.
Nausea
Select.
Suspected Internal
Haemorrhage
Select.
Other - Specify
Select.
Swollen Joint
Select.
Pacemaker Problem
Select.
Swollen Limb
Select.
Pain
Select.
Tension Pneumothorax
Select.
Palpitations
Select.
Throat Infection
Select.
Panic Attack
Select.
Throat Problem
Select.
Pneumonia
Select.
Toothache
Select.
Pneumothorax
Select.
Transient Ischaemic Attack
Select.
Post Ictal
Select.
Unconscious
Select.
Post Immersion
Select.
Urinary Catheter Problem
Select.
Post Loss of Consciousness
Select.
Urinary Tract Infection
Select.
Psychiatric Episode
Select.
Urine Retention
Select.
PR Bleeding
Select.
Vertigo
Select.
Pulmonary Aspiration
Select.
Visual Disturbance / Loss
Select.
Pulmonary Embolism
Select.
Vomiting
Select.
PV Bleeding
Select.
Weakness
Select.
Rash
Select.
Wound Inflammation /
Infection
Select.
Renal Calculi / Colic
Select.
Wound / Puncture
Select.
NSW Ambulance eMR Data Request Form
13
Description
Required? 
Justification for this request
Vital Signs Survey (VSS)
Time
Of observation
☐
Click here to enter text.
Pulse
Beats/minute
Systolic/Diastolic or
palpable
Breaths/minute
00 = No pain
10 = Worst pain
o
C
☐
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☐
Click here to enter text.
☐
Click here to enter text.
☐
Click here to enter text.
☐
Click here to enter text.
☐
Click here to enter text.
☐
Click here to enter text.
Skin
☐
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Temperature
☐
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Colour
☐
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Moisture
☐
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Blood pressure
Respiratory rate
Pain (score)
Temperature
Route
Blood sugar level (BSL)
mmol/l
Glasgow Coma Score (GCS)
Total/15
☐
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Eye Opening
/4
☐
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Verbal Response
/5
☐
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Best Motor Response
/6
☐
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☐
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Pupils (L/R)
Size
mm
☐
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Reactivity to light
Yes, no
☐
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APGAR score for newborns
Total/10
☐
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Appearance
0-2
☐
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Pulse
0-2
☐
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Grimace
0-2
☐
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Activity
0-2
☐
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Respiratory effort
0-2
☐
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☐
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Electrocardiograph (ECG)
Rate
Beats/minute
☐
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Rhythm
Heart rhythm
☐
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Blocks
Type (e.g. LBBB)
☐
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Ectopy
Type
☐
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Ischaemia
Cardiac location
☐
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Oxygen saturation (SpO2)
%
☐
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oxygen/air
Select
☐
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☐
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End tidal CO2
☐
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Waveform
Description
☐
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Respiratory status
Degree of distress
Includes child pain
score
☐
Click here to enter text.
☐
Click here to enter text.
mmHg
Paediatric vital signs
NSW Ambulance eMR Data Request Form
14
Management: Procedures and medications. Indicate required fields in TABLE below
Justification for this request:Click here to enter text.
Click here to enter text.
Abdominal Thrusts (Adult) ☐
Dressing - Wound / Burns
Cover ☐
Isoprenaline Hydrochloride ☐
Paracetamol 500mg/Codeine 30mg ☐
Enoxaparin Sodium ☐
Extracorporeal Membrane
Oxygenation ECMO ☐
Ketamine ☐
Parecoxib Sodium ☐
Laryngeal Mask Airway ☐
Pethidine Hydrochloride ☐
Adrenaline ☐
Advice to Patient/Carer Specify ☐
Extrication ☐
Lateral Chest Pressure ☐
Phenytoin ☐
Ergometrine ☐
Lateral Chest Thrust (Paed) ☐
Potassium Chloride ☐
Airway Clearance ☐
Fentanyl ☐
Lignocaine ☐
Position ☐
Amiodarone ☐
Fexofenadine ☐
Hydrochloride ☐
Magnesium Sulphate ☐
Prasugrel ☐
Apnoea (Prescribed) ☐
Frusemide ☐
Mannitol ☐
Pre Cordial Thump ☐
Arterial Line ☐
Gastric Tube ☐
Prochlorperazine ☐
Aspirin ☐
Glucose - Oral ☐
MAST ☐
Mental Health - EEO
Completed ☐
Assistance Only ☐
Glucagon ☐
Metaraminol Bitartrate ☐
Propofol ☐
Atracurium ☐
Atropine Sulphate / Obidoxime
Chloride ☐
Glucose 5% ☐
Methoxyflurane ☐
Restraints Applied ☐
Glucose 10% ☐
Metoclopramide ☐
Restraints Removed ☐
Atropine ☐
Glucose 50% ☐
Metoprolol ☐
Reassurance Provided ☐
Back Blows ☐
Glyceryl Trinitrate ☐
Midazolam ☐
Resuscitation Ceased ☐
Balloon Pump ☐
Haemorrhage Control ☐
Misoprostol ☐
RICE ☐
Benztropine ☐
Haloperidol ☐
Rocuronium ☐
Benzylpenicillin Sodium ☐
Hartmanns ☐
Morphine Sulphate ☐
Midazolam / Morphine
Infusion ☐
Blood Product ☐
Helmet Removal ☐
Naloxone Hydrochloride ☐
Sling ☐
Box Jellyfish Antivenom ☐
Heparin ☐
Nasopharyngeal Airway ☐
Sodium Bicarbonate 8.4% ☐
Calcium Chloride 10% ☐
Humidicrib / Portacot ☐
Hydrocortisone Sodium
Succinate ☐
Nitrous Oxide / Oxygen ☐
Spinal Immobilisation ☐
Nifedipine ☐
Splint ☐
Ceftriaxone ☐
Hypertonic Saline 7.5% ☐
Noradrenaline ☐
Suxamethonium Chloride ☐
Central Venous Access ☐
Hypertonic Saline 20% ☐
Normal Saline ☐
Synch Cardioversion ☐
Chest Thrusts ☐
Ibuprofen ☐
Ondansetron ☐
Tenecteplase ☐
Childbirth ☐
Ice Pack/s ☐
Infection Control Measures Pt Based ☐
Oropharyngeal Airway ☐
Tension Pneumothorax Needle Test ☐
Oseltamivir ☐
Thoracostomy ☐
Compression Bandage ☐
Continuous Positive Airway
Pressure CPAP ☐
Influenza Virus Vaccine ☐
Other Equipment ☐
Tirofiban ☐
Insulin ☐
Other Medication ☐
Trial Equipment ☐
CPR ☐
Intercostal Catheter ☐
Urinary Catheter ☐
Cricothyroidotomy ☐
Intraosseous Needle ☐
Other - Specify ☐
Other Therapeutic Procedure
☐
Defibrillation ☐
Intubation ☐
Oxygen Therapy ☐
Vecuronium ☐
Dexamethasone ☐
Intubation Check ☐
Oxymetazoline ☐
hydrochloride ☐
Ventilation - Manual
Diazepam ☐
Ipratropium Bromide ☐
Oxytocin ☐
Ventilation - Mechanical ☐
Dobutamine ☐
Irrigation ☐
Pacing ☐
Verapamil Hydrochloride ☐
Dopamine ☐
IV Access ☐
Pancuronium Bromide ☐
Vinegar ☐
Paracetamol ☐
Wheelchair ☐
Revised assessment
Assessment following examination. RERERENCE TABLE 3, page 12. Please print another copy of TABLE
3 if required Revised Assessment variables differ from selected Initial, Primary or Secondary
Assessment fields.
Activated Charcoal ☐
Adenosine ☐
Calcium Gluconate 10% ☐
Clopidogrel hydrogen sulfate ☐
NSW Ambulance eMR Data Request Form
Promethazine ☐
Salbutamol ☐
Valsalva Manoeuvre ☐
15
Protocols: Paramedics select one chief protocol / one or many associated protocols. Indicate required fields in TABLE below
Justification for this request: Click here to enter text.
Click here to enter text.
Foundation care
M20 Gastroenteritis ☐
T7 Limb injuries and fractures ☐
S3 Mental health emergency ☐
A1 Principles pre-hospital care ☐
M21 Hypoglycaemia ☐
T8 Penetrating trauma ☐
S4 Assault/sexual assault ☐
A2 Basic patient care ☐
M22 Hyperglycaemia ☐
T9 Pelvic injuries ☐
S6 Suicide risk asses manage ☐
A3 Informed consent, capacity,
competency ☐
M23 Sepsis ☐
T10 Traumatic hypovolaemia ☐
S8 Elderly at risk ☐
A4 Medication administration ☐
M24 Adrenal crisis ☐
T11 Soft tissue face and neck ☐
S9 Palliative care ☐
A5 Recognition sick baby child ☐
M25 Medical hypoperfusionhypovolaemia ☐
T12 Burns ☐
Drug/toxicology
Cardiac/cardiovascular
C1 Acute coronary syndrome
☐
T13 Eye injuries ☐
D1 Drug overdose poisoning ☐
T14 Electric shock ☐
D2 Organophosphate poison ☐
A6 Pain management ☐
A7 Patient management ☐
A8 Urgent transport ☐
C2 Resuscitation decision
algorithm ☐
T15 Trapped patient ☐
D3 Alcohol intoxication ☐
A9 Bariatric patients ☐
C3 Cardiac arrest ☐
T16 Limb realignment, difficult
extrication ☐
D4 Oleoresin capsicum spray
exposure ☐
Medical
C5 Cardiogenic pulmonary
oedema ☐
T16A Limb realignment, difficult
extrication – Ketamine ☐
D5 Nerve agent poisoning ☐
M1 Abdominal conditions ☐
C6 Cardiogenic shock ☐
T17 Deteriorating trauma patient
☐
Obstetrics/newborn
M2 Airway obstruction foreign body
☐
C7 Bradycardia ☐
T18 Wound care ☐
O1 Obstetric general protocol ☐
M4 Asthma ☐
C8 Tachycardia ☐
T19 Falls in the elderly ☐
O2 Pregnancy related PV
haemorrhage ☐
M6 Nausea & Vomiting ☐
C9 Hyperkalaemia ☐
T20 Traumatic cardiac arrest ☐
O3 Postpartum haemorrhage ☐
M7 Croup ☐
C11 Stroke ☐
Environment/envenomation
O4 Prolapsed umbilical cord ☐
M8 Dehydration ☐
C12 Cardiac reperfusion –
Primary angioplasty ☐
E1 Chemical biological
radiological (CBR)/HAZMAT ☐
O5 Pregnancy related
hypertension ☐
M9 Seizures ☐
C13 Cardiac reperfusion –
Prehospital thrombolysis ☐
E2 Diving emergencies ☐
O6 Newborn care ☐
M13 Meningococcal septicaemia ☐
Trauma
E3 Hyperthermia ☐
Patient transport decisions
M14 Respiratory distress ☐
T1 Major trauma ☐
E4 Hypothermia ☐
P1 Authorised care ☐
M15 Autonomic dysreflexia ☐
T2 Multiple victim situations
☐
E5 Drowning ☐
P2 Patient refuses paramedic
advice ☐
M16 Anaphylaxis, allergic ☐
T3 Helicopter operations –
major trauma – “Primary” ☐
E6 Bites and Envenomation ☐
P5 Referral decision ☐
M17 Epistaxis ☐
T4 Head injuries ☐
E7 Smoke noxious gas, carbon
monoxide poisoning ☐
P6 Incident control another
agency ☐
M18 Dental problems ☐
T5 Spinal injuries ☐
Specialised care
P7 Non transport – Non health
issues ☐
M19 COPD ☐
T6 Chest injuries ☐
S1 Home dialysis emergency ☐
NSW Ambulance eMR Data Request Form
16
Required? 
Justification
Details of vehicle
☐
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Vehicle type
☐
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State
☐
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Vehicle registration
☐
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☐
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Impact type
☐
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Helmet status
☐
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Helmet damage
☐
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Mode of impact
☐
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Description
RTA
Motor cyclist details
Road traffic accident details
Cyclist or motorbike
☐
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Vehicle safety details
Seat belt, airbags etc.
☐
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Vehicle impact details
Speed, direction, damage
☐
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Patient information
Crushed, trapped, ejected etc.
☐
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Other vehicle
NSW Ambulance eMR Data Request Form
17
Description
Required? 
Justification
Billing
Section 20,
pensioner
type, police
custody etc.
☐
Patient not treated
Reason
☐
Patient not transported
Click here to enter text.
Referral
Reason
☐
Problem at
RERERENCE
time of
TABLE 3,
paramedic
page 12
discharge
Specialised Medical Service
Indicate required fields:
Assessment Team
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Doctor
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Patient
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Social Worker
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Case Worker
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000 Referral Service
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Other Team
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NETCOM
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Other Health Professional
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Police
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Drug Referral Service
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Detox Service
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Family
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Other - Specify
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Observed outcome
Unknown
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Indicate required fields:
Dead on arrival
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Died at scene
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Died en route
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Died in ED/hospital
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ROSC at hospital
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Billing type
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Result
Final assessment
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☐
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Final odometer
☐
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Total trip odometer
☐
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Major trauma criteria?
Transport reason
Protocol T1
☐
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Time
Reason
E.g. ‘lights &
sirens’ from
scene
Load time
☐
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Destination type
E.g. hospital
☐
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Hospital name
Hospital name
☐
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Destination name
If not hospital
To/from
another crew
☐
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☐
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Transport code
Patient handed over
NSW Ambulance eMR Data Request Form
Click here to enter text.
18