E-Patient Report Form

Duty Manager: Liam Booth

Date-job number eg: 010220021-123 (or CAD Number)

Street Address

Street Address Line 2

CityCounty

Postcode

MaleFemaleOther - Specify below

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

What happened? How did it happen? What were they doing?

Slurred/AbnormalNormal

YesNo - Act in the patient's best interests.

YesNo - go to refusalUnable (implied consent) - Act in patients best interest

Tested - PositiveTested - NegativeUntested - SymptomaticUntested - No Symptoms

Yes - Shock AdvisedYes - No Shock AdvisedNo

NoYes - 3LeadYes - 12Lead

Please attach copy of ECG below

Use when above table is not accessible

Images of injuries, scene, vehicle damage or other relevant items

I, the medical professional confirm that the patient has full capacity under the Mental Capacity Act 2005 to refuse treatment. I have informed the patient of the associated risks and also given worsening advice and details of how to seek help if required later.

I, the patient have been advised that I require medical attention but wish to refuse and decline this at this time. I have been informed of the risks that may occur from refusing treatment, including further injury or death. I understand that if I wish to obtain medical treatment I can at any point by cailing 999/112 or presenting at any accident and emergency department. I confirm that the assessing medical professional and the company they represent accept no liability for any further harm that may come due to the refusal of treatment.

Crew details, hospital details, police collar numbers, outside agency details

Or paitents own signature if discharged from scene

Patient Report Form

Patient Details

GP Details

Next Of Kin

Initial Assessment

Cardiac Arrest/ROSC

Clinical Observations

Initial Observations

Glasgow Coma Score

Treatment

Recognition Of Life Extinct

Refusal of treatment

Treated by

Discharge/Handover Information