From the Guidelines
A comprehensive divers medical charting template should prioritize respiratory fitness assessment, including history, examination, and lung function tests such as FEV1, FVC, and PEF, as outlined in the British Thoracic Society guidelines 1. When creating a divers medical charting template, several key components should be included to effectively document a diver's medical status.
- Basic patient information: name, age, date of birth, and contact details
- Diving history: certification level, number of lifetime dives, and recent diving activity
- Medical history: pre-existing conditions, medications, allergies, and previous diving-related medical issues The physical examination portion should document:
- Vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation
- Cardiopulmonary assessment
- Neurological examination
- Ear/sinus evaluation As recommended by the British Thoracic Society guidelines 1, the template should also include:
- Assessment of respiratory fitness to dive, with particular attention to current respiratory symptoms, previous history of lung disease, and previous episodes of pneumothorax
- Respiratory system examination
- Lung function tests: FEV1, FVC, and PEF, with FEV1 and PEF normally greater than 80% of predicted and the FEV1/FVC ratio greater than 70% 1
- Chest radiography, if indicated by a previous history of significant respiratory illness or current respiratory symptoms and/or abnormal examination findings 1 For dive-related injuries, the template should include:
- Onset timing
- Depth profiles
- Gas mixtures used
- Decompression procedures followed
- Specific symptom progression Treatment documentation should record:
- Oxygen administration: concentration and duration
- Rehydration: type and volume of fluids
- Medications administered
- Recompression therapy details: treatment tables used The template should conclude with:
- Disposition planning
- Follow-up recommendations
- Diving clearance status By prioritizing respiratory fitness assessment and including these key components, the template can ensure comprehensive documentation and facilitate appropriate medical care for diving-related conditions, as supported by the British Thoracic Society guidelines 1.
From the Research
Divers Medical Charting Template
- A medical charting template for divers should include the following information:
- The template should also include space for noting the patient's vital signs, such as blood pressure, heart rate, and oxygen saturation
- Additionally, the template should include a section for documenting the patient's response to treatment, including any improvements or worsening of symptoms
Components of the Template
- Patient identification and demographics
- Diving history and symptoms
- Physical exam and diagnostic test results
- Treatment plan and medication administration
- Progress notes and response to treatment
Importance of Accurate Documentation
- Accurate and thorough documentation is crucial in the treatment of decompression sickness 2, 3, 4, 5, 6
- The medical charting template should be designed to ensure that all relevant information is collected and documented in a clear and concise manner
- This will help ensure that patients receive appropriate treatment and follow-up care, and will also facilitate communication among healthcare providers 2, 3, 4, 5, 6