Patient Report Form

Date: Casualty Age: ☐ < 18 ☐ > 18 Casualty Sex: ☐ M ☐ F URN:

Time On Scene: Time Off Scene: Time EMS Arrived: Firearms Deployment: ☐

Transport: ☐ Land Ambulance ☐ Air Ambulance ☐ Police Vehicle ☐ Other

Hospital: ☐ Example 1 ☐ Example 2 ☐ Example 3 ☐ Example 4

Mechanism of Injury: ☐ Blunt trauma ☐ Penetrating injury ☐ Medical ☐ Mental health

☐ Stabbing ☐ Alcohol/ drugs ☐ Vehicle RTC ☐ Self-harm

☐ Shooting ☐ Punched/ kicked ☐ Pedestrian hit by vehicle ☐ Suicide / parasuicide

☐ Burn ☐ Hanging ☐ Cyclist ☐ Fall < 6ft ☐ Fall > 6ft

☐ Other (please specify):

Injuries

Notes:

(Please use numbers to code and mark location of injuries on body map)

☐ ☐
1. Amputation 6. Fracture closed
☐ ☐
2. GSW entry 7. Burns
☐ ☐
3. GSW exit 8. Head injury
☐ ☐
4. Stab 9. Laceration
☐ 10. Other ☐
5. Fracture open
(please sepecify):
 Airway: ☐ Clear ☐ ☐ Breathing ☐ Not
On arrival ☐ Cat Haem 1. ☐ A ☐ V ☐ P ☐ U
Obstructed Breathing
Observations carried out by EMS ☐

Airway Breathing Circulation

Rate Tourniquet ☐
Clear ☐
1. ☐ <10 ☐ 10-30 ☐ >30 ☐ Rt arm ☐ Lt arm ☐ Rt leg ☐ Lt leg
2. ☐ <10 ☐ 10-30 ☐ >30
Obstructed Snoring ☐ External Bleeding ☐
☐ Patient position
☐ Chin lift Bleeding Wound
☐ Jaw thrust Volume/ Effort ☐ Direct pressure
☐ NP; size ☐ 6 ☐ 7 ☐ Normal
Dressing
☐ OP; size ☐ 3 ☐ 4 ☐ 5 ☐ Abnormal
☐ Field ☐ Blast
☐ SGA; size ☐ 3 ☐ 4 ☐ 5
☐ Windlass ☐ Haemostatic
Internal Bleeding suspected
Obstructed Gurgling ☐ Oxygen ☐ % O2 Saturations ☐ Chest ☐ Abdomen
☐ Patient turned ☐ High flow mask 1 ☐ < 95 ☐ > 95 ☐ Pelvis ☐ Long Bones
☐ Suction ☐ BVM 2 ☐ < 95 ☐ > 95 Pelvis / Femur Fracture
☐ Splint
Complete Obstruction ☐
☐ Back blows FLASH ☐
Radial Pulse
☐ Abdominal / chest thrusts
1. ☐ ☐ < 60 ☐ 60-120 ☐ >120
Holes
2. ☐ ☐ < 60 ☐ 60-120 ☐ >120
Soft tissue facial injury ☐ Front: ☐ L ☐ R Chest seal ☐ Vented ☐ Non vented
Back: ☐ L ☐ R Chest seal ☐ Vented ☐ Non vented
Bony facial injury ☐ Bruising / abrasion ☐
C-Spine No Pulse ☐
Rib Fractures / Flail Chest
☐ Normal
☐ Splinted ☐ CPR ☐ AED ☐ ROSC ☐ Dead
☐ Suspected injury
☐ Patient self-splinted
☐ Manual control

Disability Exposure for Examination

☐ Fully undressed ☐ ? Spinal injury Burns
2. ☐A ☐V ☐P ☐U ☐ Clingfilm
☐ Logroll ☐ Patient cold ☐ < 10 mins irrigation
3. ☐A ☐V ☐P ☐U ☐ Diphoterine
☐ Back & sides check ☐ Patient covered ☐ 10 - 20 mins irrigation

Pain
Initial Pain Score Patient complaining of pain? ☐
Penthrox used: Y ☐ N ☐
0 1 2 3 4 5 6 7 8 9 10
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Number of vials used: 1☐ 2☐
☐
After Dose 1 Time:
Batch Number: Signature:
0 1 2 3 4 5 6 7 8 9 10
Expiry date:
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
After Dose 2 Time:
Batch Number: Signature:
0 1 2 3 4 5 6 7 8 9 10
Expiry date:
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Confirmed: ☐
Breathing No contraindications
Adverse Reaction to Penthrox:
Past medical history / Medication
☐ Rate > 10 Y☐ N☐
No use of Penthrox in last 3 months
☐ Normal breathing If yes, please specify:
Alert card given & discussed
Consent obtained
ADRs reported to CG lead ☐
Radial pulse Name:
Handover to EMS ☐
☐ Present
Date:
Age
Name of staff receiving patient / EMS call sign:
☐ > 18 years
Notes on Penthrox use:
☐ Currently Alert & able to obey commands

Overall Patient Outcome:

Signature: Date:

Internal review by: External Review by: