Incident assessment and record keeping
This domain tests the paperwork and information side of first aid: what you observe, what you did, when you did it, and how you hand it over. The exam expects factual, contemporaneous records that support continuity of care and protect everyone involved. It also expects you to know that documentation never delays emergency care.
Core rules and concepts
- Record facts, not opinions. Write “casualty said they felt dizzy and had a graze to the left palm” rather than “casualty was careless.”
- Use a clear timeline. Note the time you arrived, the time help was called, changes in responsiveness or breathing, treatments given, and the time of handover.
- Identify the casualty and incident. Record name if known, age, location, mechanism of injury, and who was present. If the casualty cannot consent, record why.
- Describe observations and treatment. Include AVPU level, breathing, skin colour, bleeding control, dressings applied, and any medication the casualty took themselves.
- Sign and date. A record without a name, date, and signature is weak. Correct errors with a single line, initial, and date; do not erase or overwrite.
- Store confidentially. Follow employer policy and data protection rules. Provide information to ambulance staff or the employer only as needed for care or investigation.
- Handover verbally as well as in writing. Tell receiving staff what happened, what changed, and what you did.
Worked example
A worker cuts their hand on a metal edge. The first aider wears gloves, cleans the wound, applies a sterile dressing, and checks the hand’s circulation. They record: “14:05 arrived; 14:06 999 not called, minor bleeding controlled with direct pressure; 14:10 dressing applied; casualty alert, no allergies; advised to attend minor injuries unit for tetanus review.” Reasoning: the record is timed, factual, and includes advice given without speculating about tetanus status.
Traps that cost marks
- Writing opinions, blame, or unverified diagnosis.
- Delaying urgent care while completing paperwork.
- Leaving out the time help was called or the time of handover.
- Recording confidential details in an open email or shared notebook.
- Altering a record without showing the correction.