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. 2016 May 21;24:76. doi: 10.1186/s13049-016-0268-6

Table 1.

The standardised clinical set data gathered on the observational charts

Name
Date of birth
Date and time of presentation
Who brought the patient?
From where was the patient brought?
Substances of abuse taken
 Time when taken
 Quantity taken
What has happened? (free text)
Previous medical history
 Seizures (yes/no)
 Diabetes (yes/no)
 Serious psychiatric disorder (yes/no)
 Known substance use (alcohol/opioids/other/none)
Clinical status at presentation
 Respiratory rate
 Heart rate
 Blood pressure
 Temperature
 Blood glucose level
 SpO2
 Track marks (yes/no)
 External signs of injury (yes/no)
 Nystagmus (yes/no)
 Plantar reflexes (down/inverted)
 Pupil size (large/small/normal)
Other information (free text)
During observation time (fields provided for repeated observations)
 Glasgow Coma Scale score
 Pupil reaction to light (+/+)
 Respiratory rate
 SpO2
 Symmetric movement of arms and legs
Medication given
 In ambulance
 At the casualty clinic

The clinical assessment of acute poisoning by substances of abuse at the Oslo Accident and Emergency Outpatient Clinic is based on standardised minimum clinical data gathered on a pre-set observational chart