History and Note Taking

Documentation of an Exposure Case: Guidelines (not all inclusive)
(Only use CHS or RPCC approved abbreviations)

History

HX: This section is what the caller tells you. Please include the patient’s age and weight if possible, past medicine history (meds, allergies or whether normally healthy) time since exposure, description of the exposure, and the substance (ingredients if not in PI or more than one product with a similar name). This section should always support the amount listed under the substance. Include symptoms here.

Assessment

A: This section should contain an assessment of the toxicity of the exposure. Calculations should be included to demonstrate the plausibility of the severity. If there are numerous products involved, calculations for the top three products are sufficient. Documentation of whether ASY or SYMP should also be included.

Definitions of severity of toxicity:
Nontoxic: The substance is listed in the PI as nontoxic. Also refer to NT algorithm.
Mild: Symptoms likely to be minimal or amount small enough not to cause toxicity. Pt. is ASY at time of the call.
Moderate: Pt. has mild symptoms at time of the call. The amount exposed to is sufficient to cause symptoms. Pt. requires decontamination/treatment (i.e. ipecac, L/AC/C, etc.).
Severe: Pt. ingested a life threatening amount regardless of symptoms. Pt. is having severe symptoms. Pt. requires an antidote, dialysis, ventilation, etc.
Cannot assess: Unknown amount ingested. Unknown weight of pt (thus unable to calculate exposure). Exposure to unknown substance.

Range of Toxicity

ROT: This section should contain an mg/kg amount, or a normal therapeutic max or a statement from a reference (usually PI , algorithm or possibly drug/substance manufacture). Please list reference if not the PI. A range of tox (that is applicable – oral dose for an exposure) is sufficient; do not cut and paste the entire section. If numerous products are involved, please list the top three (most dangerous and/or those which the patient may actually have a toxic amount. May use clinical effects for ocular or dermal exposures, where quantities of toxic amount are not available. If there are numerous substances involved, list all of them under substances, but pick the top three for ROT. May put calculations here also. This section should always explain why a patient was observed at home or referred to an ED. It should list a referral dose or symptom.

Plan

P: This section should include whether the patient was referred to a HCF. Any recommendations made to the caller (or the ED) should be captured here. All recommendations, labs and precautions should pertain to the exposure. May also include signs and symptoms that were discussed, but do not cut and paste large sections, unless the entire section was read verbatim. Follow-up time should be documented (may cut and paste PPL).

Follow-up

A: This section should address each point from the previous plan. Ask whether recommended treatments were completed and document whether it was done or not. Ask if any symptoms documented in the plan occurred (e.g. no SZ). Besides documenting therapies provided or not and symptoms here, also document under the related drop down boxes. Document disposition of the patient.

P: Document recommendations given, and any VS or labs pending to be obtained during the next follow-up.