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Information

This form is used to capture incident, clinical and personal information about patients presenting during our events.

Please note some incidents may be reportable under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) HSE Requirements (More Info).

Once a report has been submitted, it cannot be edited or amended further.

Please enter as much detail as possible, please be careful to select the options that best describe your patient.

Incident Details

Event Name: *

Location in Event *

Onset Date / Time *

Nature *

Outside Agencies Involved

Police

Fire Brigade

NHS Ambulance

Other

Patient Details

Patient Full Name: *

Patient Address *

Please get Patient's Full Address and Post Code

Date of Birth *

Gender *

Patient Demographic *

Patient Identifier

Race Number, Bib Number, etc

Patient Phone Number *

Next Of Kin Details:

Name/Telephone/Relationship to Patient

GP Practice Name, Address

Allergies *

Primary Survey

Primary Survey Done? *

Yes

No

Please make note of why in additional information!

Airway *

Clear

Present

Absent

Breathing *

Normal

Can't Complete Sentences

Obstruction

Circulation/Colour *

Normal

Pale

Flushed

Cyanosed

Cap Refill *

Under 2s

Over 2s

Radial Pulse *

Present

Absent

Patient Alertness *

A

V

P

U

Patient Status *

Calm

Un-Cooperative

Anxious

Abuse

Violent

Drug/Alcohol Suspected

Self-Mobilization

Mental Capacity

Time Assessed *

Does Patient Mental Capacity ? *

Yes

No

If No why have you treated Patient? *

Best Interest

Disability

Please make note of why in additional information!

Observations 1

Observations Needed *

Yes

No

Are there clinically indicated

Obs Time *

Respiratory Rate *

Sp02 *

Air

O2

Peak Flow

Heart Rate *

BP Systolic *

BP Diastolic *

Temp *

Blood Glucose *

Pupils

Left Size *

Right Size *

Left Reaction *

S = Slow, N = Normal, F = Fixed U = Unable to Assess

Right Reaction *

S = Slow, N = Normal, F = Fixed U = Unable to Assess

GCS

Eyes *

Verbal *

Motor *

Total *

Pain Score *

FAST Test *

Positive

Negative

Are you going to take 2nd set of Obs *

Yes

No

Observations 2

Obs 2 Time *

Respiratory Rate *

Sp02 *

Air

O2

Peak Flow

Heart Rate *

BP Systolic *

BP Diastolic *

Temp *

Blood Glucose *

Pupils

Left Size *

Right Size *

Left Reaction *

S = Slow, N = Normal, F = Fixed U = Unable to Assess

Right Reaction *

S = Slow, N = Normal, F = Fixed U = Unable to Assess

GCS

Eyes *

Verbal *

Motor *

Total *

Pain Score *

FAST Test *

Positive

Negative

Patient Assessment

Chief Complaint *

History of Presenting Complaint *

On Arrival *

On Examination *

Impression / Treatment *

Additional Information *

Drugs

Drugs Given *

Yes

No

Drugs *

Intis *

Date / Time Given *

Route *

Dose / % / L *

Unit *

Batch Number *

Expiry Date *

Patient Own *

Yes

No

Next Drugs *

Yes

No

Drugs *

Intis *

Date / Time Given *

Route *

Dose / % / L *

Unit *

Batch Number *

Expiry Date *

Patient Own *

Yes

No

Next Drugs *

Yes

No

Drugs *

Intis *

Date / Time Given *

Route *

Dose / % / L *

Unit *

Batch Number *

Expiry Date *

Patient Own *

Yes

No

Next Drugs *

Yes

No

Drugs *

Intis *

Date / Time Given *

Route *

Dose / % / L *

Unit *

Batch Number *

Expiry Date *

Patient Own *

Yes

No

Next Drugs *

Yes

No

Drugs *

Intis *

Date / Time Given *

Route *

Dose / % / L *

Unit *

Batch Number *

Expiry Date *

Patient Own *

Yes

No

Cannulations

Cannulations *

Yes

No

Size *

Time *

Site *

Successful *

Yes

No

Intis *

Size *

Time *

Site *

Successful *

Yes

No

Intials *

Image Upload

Drag and drop files here or Browse

Images relating to the accident, illness, scene or mechanism, ECG

Disposal *

Patient Signature *

If the Patient Refused Treatment/Transport

Medic Details

Medic Name: *

Medic Grade *

Medic PIN

Safe Guarding Referral *

Flag for Clinical Audit & Review *

RIDDOR Reportable *

If unsure please ask Team Leader or on call

Signature *

Email Address

This is so you can email a copy of PRF to the Patient or Hospital as hand over. (Please make sure you only email it to a NHS email address only) If not needed please type in jono@medicore.uk

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Incident Details

Patient Details

Primary Survey

Mental Capacity

Observations 1

Pupils

GCS

Observations 2

Pupils

GCS

Patient Assessment

Drugs

Cannulations

Medic Details

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