Appendix
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - Circulars - Maritime Safety Committee - MSC/Circular.1105 – Guidance on Responsibility and Liability Issues Related to the use of the Emergency Medical Kit/Bag and Evaluation of its use in Emergency Incidents – (25 February 2004) - Annex - Guidance on Responsibility and Liability Issues Related to the use of The Emergency Medical Kit/Bag (EMK) and Evaluation of its use in Emergency Incidents - Appendix

Appendix

EMERGENCY MEDICAL KIT
Debriefing Form
VESSEL: ................................................
             
Flag: ................     Number of Crew:  
Type: ................     Number of Passengers  
             
INCIDENT
             
Date: ................     Weather Conditions: Good
Time (local): ................       Rough
Time to the nearest Port: Hours     Very Rough
             
PATIENT
             
Crewmember Passenger Age: ................  
Accident Illness Severity Mild
          Serious
          Vital
             
Diagnosis / Symptoms:
................................................................................................................................
................................................................................................................................
................................................................................................................................
             
USER
             
Medical Doctor Speciality: ................................    
Nurse Paramedic Crew Member  
             
Telemedical Consultation (TMAS)   Yes  
        No  
             
RESULTS
             
Recovery Improvement Steady  
Worsening Death      
             
DECISION
             
Care onboard Ship Diversion Medevac  
Delay caused by the incident: ................................ Hours  
             
COMMENTS
             
(Used Medicines / Equipment, Missing Equipment, Problems, Complications, Proposals for improvement).
Parent topic: Annex - Guidance on Responsibility and Liability Issues Related to the use of The Emergency Medical Kit/Bag (EMK) and Evaluation of its use in Emergency Incidents
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