St John Cymru-Wales Patient Report Forms 2013

St John Cymru-Wales
Patient Report Forms
© St. John Cymru-Wales 2012. Version 3.0
Patient Report Form (PRF)
• The PRF is a legal and confidential document and
must be completed for every patient encounter – no
matter how minor at the time of contact
• PRFs highlight the reasons for care given and plays
a part in the continuity of care for a patient
• PRFs are audited to ensure treatment given is
appropriate and effective – plus identifies any
training needs.
Patient Report Form (PRF)
• PRFs must be factual, consistent, accurate and
written clearly and legibly
• A PRF may be used in the future:
– For action contemplated by the patient against SJCW or
another party
– By the coroner or an officer acting on their behalf
– If a criminal offence has been committed.
• Please note that if you are treating a patient on
behalf of WAST, you must complete their Patient
Report Form.
Version number of
the Patient Report
Insert the name of
the region or division
covering the duty
Contains the unique serial
number of this form
Time of first
contact with the
Enter Details of the Duty
and location. If you are
“off duty” the location of
the incident
Tick “Self – Referral”
if the patient came to
you and “Called to
Scene” if you went to
the patient
Print these details and check spelling with the patient.
If you cannot obtain details, indicate this in Section 13.
Date of Birth to be
completed in the
following format:
DD / MM / YY
To be completed in case of emergency
Any additional
information should be
recorded in Section 13.
The Presenting Complaint should indicate the primary
complaint of the patient. This should be concise and placed
into a broad category. For example…
Asthma Attack would be: “Difficulty in Breathing”
Grit in Eye would be: “Eye Injury”
Chest Pain would remain as: “Chest Pain”
A Sprain or Strain would be: “Soft Tissue Injury”
A Fracture or Dislocation would remain as: “Fracture” or “Dislocation”
This is a record of the first
observations you make of the
patient, tick the boxes that apply
Time to be recorded in 24 hrs
e.g. 2210 for ten past ten
HCP Only
Skin Colour can be:
Pale / Normal / Flushed / Cyanosed
“Air” or “O2” to be circled to indicate
how SpO2 was measured
Record Pain Score pre-and-post
treatment if required
Pre-marked numbers indicate
highest score in each section.
Actual scores to be overwritten.
Mark on the drawings any
problems that you find.
Use the key to indicate
what these are. If it is not in
the key, write down your
Positive: Signs of CVA/TIA Present
Negative: Signs of CVA/TIA Absent
Time that the symptoms
Side of the body showing
signs of CVA/TIA
Ask the patient if they have
any medical problems and if
necessary go through the
list so it acts as a prompt
Ask the patient if they are
allergic to any medicines
food or other substances.
If the answer is “No” record
“NKDA” (No Known Drug
Allergies) in the box.
List any regular medication that the
patient takes.
Indicate (if any) the Airway
Management techniques
that were used
If “Combined Advice Leaflet”
given, indicate further advice
given in Section 13.
Any patient with a wound or
Head Injury (no matter how
minor) should receive this.
If “No Treatment required” – explain
the reasons why in Section 13.
If a Defibrillator is used
record all details in this
Details recorded here will
enable you to complete
the documentation
required by
National Headquarters
Details of the equipment used
should be recorded here
This box is used by Ambulance Crews to record details of vehicle
times when they transport a patient.
It allows for two journeys to be recorded by the same crew or if two
resources are present (i.e. RRV and Ambulance)
‘Vehicle Callsign’ does not
need to be completed if the
vehicle is used as a
stationery first aid post.
This can be a
First Aid Unit, Medical
Centre, Hospital etc
Record any Medications given to
the patient including Medical Gases.
Record the type of mask
used e.g. Low, Medium or
High Concentration
Record that the patient
administers this
“As Required”
The route of drug
administration can be
found on the
PRF Reference Card
Expiry Date to be recorded
in the following format:
This box must be used to document the history of
incident and to list signs and symptoms and the
treatment given or refused.
Each entry must be dated,
timed and the name of
member printed.
Tick the most
appropriate boxes.
Tick the most
appropriate box.
This box MUST NOT be routinely signed. This should only be
signed in the case of a Decline or Refusal of Treatment.
Any patient under the age of 18 must have a refusal of treatment signed by a Parent or Guardian.
Alternatively they must be taken to a place of safety.
Declined / Refusal of Treatment
• Patients who decline treatment should be asked to sign the
disclaimer box
• Should treatment be refused, you must explain to the
patient the possible risks using simple language and
• It is unacceptable to obtain a signature when a patient is
incapable of understanding (e.g. Intoxicated, Confused etc)
• Where a patient refuses to sign, or is incapable of signing,
then this should be recorded and signed by the person
making this entry and witnessed, whenever possible.
Insert the time that SJCW stopped providing any
further treatment e.g. Handover Time at Hospital
or to an NHS Ambulance Crew
Hospital Name and Department to be noted here
e.g. UHW ED or MAU or Waiting Room etc
This box MUST be completed on every
occasion as this is an area which is
often picked up by event organisers
and/or solicitors if further action is taken
concerning an incident.
Tick the box that applies.
Note any Safeguarding concerns. These
patients should ideally be conveyed to Hospital
and concerns passed to a HCP
Assistance can be gathered from
Regional Safeguarding Officers
Print your Name
and/or ID Number in
this box
This is your qualified role within
St. John Cymru-Wales:
This box should
contain your
FA: First Aider
PTA: Patient Transport Attendant
ETA: Emergency Transport Attendant
Para: Paramedic
Tech: Technician
Nurse: Nurse
Doctor: Doctor
Complete the PRF….
• You are on duty at the Royal Welsh Show when a
gentleman attends your First Aid Unit assisted by a
friend. The time is 13:35
• He tells you that he was in the Equestrian Area when he
tripped over a rope. He is bleeding from a wound above
is left eyebrow and has pain in his right wrist
• His name is Adam Phillip Jones and lives at 12 Fairview
House, The Mews, Bradley. AC2 2GA
• His date of birth is 14th August 1920.
• He is Alert, Airway is clear, Breathing is normal but looks
• He tells you that he was not unconscious and this is
confirmed by the friend
• His friend also informs you that the patient has Angina
and Osteoporosis
• He tells you he is not allergic to anything and has a GTN
Spray and Ibuprofen.
• On examination, you note a wound above his left
eyebrow which has minor bleeding and pain in his right
wrist which you suspect is a fracture
• Observations at 13:40 is that he remains Alert,
Respirations are 22 and Pulse is 119, SpO2 is 99% on
Air, BP is 128/88 and a BM of 5.6
• Capillary Refill time is less than two seconds
• Pain Score is noted as 10 out of 10.
• GCS is 15 and Pupils are equal and reactive to light and
are 4 mm in diameter
• You clean the head wound with saline solution and apply
a dressing prior to resting the arm in an Arm sling
• At 13:45, you administer Entonox and Paracetamol (1g)
• Observations at 13:50: he remains Alert, Respirations
are 20 and Pulse is 115, SpO2 are 98% on Air and BP
126/86. Pain Score is 3 out of 10 with Entonox.
• GCS is 15 and Pupils are equal and reactive and remain
4 mm in diameter
• He is seen by the duty Nurse at 13:50 who suspects a
“Colles fracture” to the wrist, fingers are swelling but
circulation is satisfactory.
• The Nurse advises he is taken to hospital by Ambulance.
• A St John Vehicle (HQ160) is requested at 14:00 and
arrives at 14:04
• He is able to walk to the ambulance with assistance and
they leave for Hospital at 14:05
• The Ambulance arrives at Bronglais General Hospital at
15:15 and handed over to the Triage Nurse at 15:25
• The patient is taken to the Minor Injuries Unit (MIU).
PRF Training Package
Children under 16 years of age
Consent for treatment and to share information
• Always be aware that the welfare of a young person is
• If the young person indicates for treatment to be given;
but do not want information to be shared with a parent,
guardian or other party, the member treating must follow
this protocol…
Children under 16 years of age
• Explore the option of possibly involving and informing the
parent or guardian
• Be satisfied that the young person has sufficient maturity
to understand the nature, purpose and likely outcome of
the treatment proposed
• Be satisfied that what is proposed by the young person is
in the young person’s best interest.
Children under 16 years of age
• If the above protocol is met, the young person is regarded
as competent to give consent
• In all cases, decisions must be made in the best interests
of the child at all times
• These facts must be formally recorded on the PRF in the
“Additional Notes” section
• If in doubt, advice should be sought from a Senior
Volunteer, Healthcare Professional, WAST or the Police.
Unwell Members on Duty
• If a member was to become unwell on duty, the SJCW
Accident Procedure should be followed by completion of
AC-1 in addition to a PRF
• If this is a Youth member, SJCW has a duty to inform the
Parent or Guardian immediately.
Treatment carried out
when not on duty
• If you attend to a member of the public and you are
not on a duty you must still complete a PRF form.
This can be done at the incident or immediately after.
• Remember to tick the “off duty box” to ensure that it is
recorded accurately
White Copy
• This copy is retained by St. John Cymru-Wales and
must be sent to National Headquarters for audit and
storage within one month of the incident date.
Pink Copy
• The patient is entitled to receive the pink copy of
their Report Form and this should be offered to
them at the conclusion of treatment
• If they decline to accept the form then it should
remain with the original (white copy)
• The exception to this is where the patient is taken
or sent to hospital when the pink copy should be
handed over to either the Ambulance Service
personnel or to Hospital staff.
Frequently Asked Questions
And Finally
If you have any comments or questions about the
Patient Report Forms, please contact:
Abi Maciver, Volunteer Manager on 02920 449648
or by e-mail to: [email protected]

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