Forum E-Patient Report Form

Treatment
Treatment Given
Cannulated?

YesNo
Location And Size
Drugs Given (PGDs)
Airway Adjunct Used?
Time of insertion

Hour Minutes
Patient Intubated?

YesNo
Time of intubation

Hour Minutes
Other information
Additional images

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

Refusal of treatment
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.
Signature

Clear
Name

First NameLast Name
Time

Hour Minutes
Date

DayMonthYear
Date
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.
Signature of patient

Clear
Patient Name

First NameLast Name
Time

Hour Minutes
Date

DayMonthYear
Date
Witness Signature

Clear
Witness Name

First NameLast Name
Time

Hour Minutes
Date

DayMonthYear
Date

Discharge/Handover Information
Time of discharge/handover

Hour Minutes
Discharge/Handover route
Further Information
Crew details, hospital details, police collar numbers, outside agency details
Signature of receiving party

Clear
Or paitents own signature if discharged from scene
Name

First NameLast Name
Receiving person
Send Copy To Receiving Centre
3rd Party Email
Safeguarding referral made?

YesNo
Should be Empty:

Patient Report Form