PRF – Lite: Patient Report Form

PRF – Lite: Patient Report Form

Complete all sections for emergency patient documentation and handover. Based on ERT SAR – Patient Report Form – Lite Version.
REPORT DATE*

MonthDayYear
Date
Hour Minutes
BY*
PATIENT NAME*
AGE
State approx . age if not known
DOB (dd/mm/yy)

DayMonthYear
Date
SEX OF PATIENT
TEL (Mob / H / W)
Please enter a valid phone number.Format: (000) 000-0000.
ADDRESS

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
WITNESS
WITNESS TEL
Please enter a valid phone number.Format: (000) 000-0000.
O2N2O2CPRDEFIBTQ
SIGNS/SYMPTOMS
What can you see (signs, like bleeding) and what does the person feel (symptoms, like dizziness or pain)?
ANY ALLERGIES
Ask about allergies to medication, food, or environmental factors.
MEDICATION
Is the person taking any prescriptions or over-the-counter medications?
PERTINENT PAST MEDICAL HISTORY
Does the person have any pre-existing medical conditions (e.g., diabetes, epilepsy)?
LAST ORAL INTAKE
When did the person last eat or drink anything? What was it?
HISTORY (Hx) INJURY OR ILLNESS
What was the person doing just before the incident happened?
TREATMENT (Tx) SO FAR?
Vitals taken? Dressing applied? Ice? Medication given? etc.
1st Set of VITAL SIGNS:

Record first set of vital signs below.
1 BLOOD PRESSURE SYSTOLIC (mmHg)
1 BLOOD PRESSURE DIASTOLIC (mmHg)
1 HEART RATE (bpm)
1 O2 SATS (%)
1 BLOOD SUGAR (mmol/L)
1 PUPILS
PEARL (Pupils Equal and Reactive to Light)
Annotate Image
2nd Set of VITAL SIGNS:

Record second set of vital signs below.
2 BLOOD PRESSURE SYSTOLIC (mmHg)
2 BLOOD PRESSURE DIASTOLIC (mmHg)
2 HEART RATE (bpm)
2 O2 SATS (%)
2 BLOOD SUGAR (mmol/L)
2 PUPILS
PEARL (Pupils Equal and Reactive to Light)
AMBULANCE HANDOVER IF APPLICABLE (WHO TO?)
N/A if no handover or details of the Ambulance
AMBULANCE ARRIVAL TIME

MonthDayYear
Date
Hour MinutesAM/PM Option
AMBULANCE HANDOVER TIME

MonthDayYear
Date
Hour MinutesAM/PM Option
To be completed before handover / file. For more information: www.ERT-SAR.com | FORMS@ERT-SAR.com
Should be Empty:

PRF – Lite: Patient Report Form

1st Set of VITAL SIGNS:

2nd Set of VITAL SIGNS: