1. St John Cymru-Wales Patient Report Forms 2013 © St. John Cymru-Wales 2012. Version 3.0

2. 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.

3. 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.

5. Version number of the Patient Report Form Contains the unique serial number of this form Insert the name of the region or division covering the duty Completion Instructions

6. Enter Details of the Duty and location. If you are “off duty” the location of the incident Time of first contact with the patient Tick “Self – Referral” if the patient came to you and “Called to Scene” if you went to the patient

7. 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

8. 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” Any additional information should be recorded in Section 13.

9. This is a record of the first observations you make of the patient, tick the boxes that apply

10. Time to be recorded in 24 hrs e.g. 2210 for ten past ten Skin Colour can be: Pale / Normal / Flushed / Cyanosed PTA & ETA or HCP Only “Air” or “O2” to be circled to indicate how SpO2 was measured Pre-marked numbers indicate highest score in each section. Actual scores to be overwritten. Record Pain Score pre-and-post treatment if required

11. 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 observation Time that the symptoms appeared FAST Face Arm Speech Test Positive: Signs of CVA/TIA Present Negative: Signs of CVA/TIA Absent Side of the body showing signs of CVA/TIA

12. 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.

13. 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.

14. If a Defibrillator is used record all details in this box. Details recorded here will enable you to complete the documentation required by National Headquarters Details of the equipment used should be recorded here

15. 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) This can be a First Aid Unit, Medical Centre, Hospital etc ‘Vehicle Callsign’ does not need to be completed if the vehicle is used as a stationery first aid post.

16. Oxygen Record the type of mask used e.g. Low, Medium or High Concentration Record any Medications given to the patient including Medical Gases. Entonox 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: MM / YY

17. 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.

18. Tick the most appropriate boxes.

19. Tick the most appropriate box.

20. 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.

21. 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 terminology 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.

22. Insert the time that SJCW stopped providing any further treatment e.g. Handover Time at Hospital or to an NHS Ambulance Crew 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 Hospital Name and Department to be noted here e.g. UHW ED or MAU or Waiting Room etc

23. This box should contain your Signature. Print your Name and/or ID Number in this box This is your qualified role within St. John Cymru-Wales: FA: First Aider PTA: Patient Transport Attendant ETA: Emergency Transport Attendant Para: Paramedic Tech: Technician Nurse: Nurse Doctor: Doctor

24. Complete the PRF….

25. Scenario 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 14 th August 1920.

26. Scenario He is Alert, Airway is clear, Breathing is normal but looks Pale 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.

27. Scenario 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.

28. Scenario 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)

29. Scenario 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.

30. 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). Scenario

31. ADDITIONAL INFORMATION PRF Training Package

32. Children under 16 years of age Consent for treatment and to share information Always be aware that the welfare of a young person is paramount 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…

33. 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.

34. 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.

35. 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.

36. 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

37. 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.

38. 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.

39. Frequently Asked Questions

40. 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: abi.maciver@stjohnwales.org.uk.abi.maciver@stjohnwales.org.uk