Textbook of Maritime Medicine

13.18.1. Information for the captain

Information in the report should allow the captain to judge the condition in a way that he can evaluate the risk of keeping a patient on board and also can estimate the abilities of the seafarer to return to work. It may also be necessary to report whether a condition holds a risk for the rest of the crew, e.g. in case of infectious disease. In that case a further instruction how to handle the case has to be added to the report.


13.18.2. Medical information

All medical information should be handed to the patient and is his property and responsibility. Medical details and results of tests have to be handed over to the patient because he may have to use them in another consultation. Copies of the report and the result are to be kept in the medical file of the port medical service. Other interested parties like insurances, representatives of the company etc… should get the information that the national regulations allow them to get.

13.18.3. The medical records should contain:

Name and First name
Date of Birth
Nationality
Gender
Rank on board

Identification of the Vessel

Name of the ship
Type of ship
Information of the voyage: trading area, cargo, next port, time in port, ETD.
Agency + phone No.
Transport company to the vessel + phone No.
Quay (name or number)
History of the present illness / injury
Objective findings
Specialized examinations or test results
Assessment
Planning
Treatment
Duty Status

Not only should the duty status be indicated with regard to the work a person can do on board; is he completely FIT? Completely UNFIT? Can he do limited tasks? What tasks? Be as specific as possible. But the duty status should also indicate if it is SAFE for the patient to remain on board. e.g. A patient with a complicated bandage may be able to perform watch duties, but in case of an
emergency, like an abandon ship alarm, this man would not be able to save himself and would depend on others. Such argument may be enough to sign him off. This argument however then has to be placed in a context of type of ship, kind of voyage and also social network of the seafarer.