Confidential Patient Care Record

Jump To Patient Observations?

YESNO

PCR DATE* This field is required.

Date

Time Of Call

Hour

Minutes

Race Or Runner Number

Does The Patient Consent To Treatment And Collection Of Personal Information?* This field is required.

YESNO

Time In Attendance

Hour

Minutes

Patient Name* This field is required.

First Name

Last Name

Patients Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Patients Phone Number

Area Code

Phone Number

Date Of Birth

Date

Is Patient Over The Age Of 16* This field is required.

YESNO

Patients NOK And Contact Number As Patient Is Under 16 Years Of Age

Has Parent/Guardian Consent Been Obtained For This Patient?

YESNO

Description Of Safeguarding Measures And Life Saving Treatments Provided Without Consent For Patient (POLICE OR SAFEGUARDING OFFICER MUST BE CONTACTED) Details.

On Balance Has The Patient Capacity To Accept And Refuse Treatment* This field is required.

YESNO

Reasons On Balance Capacity Is Not Established And Control Measures Implemented.

Any Allergies* This field is required.

YESNO

List Of Patients Allergies

Primary Survey (Catastrophic Haemorrhage)

YESNO

Catastrophic Haemorrhage DetailsLocation Of Haemorrhage, Internal/External, & Estimation Of Volume

Catastrophic Haemorrhage Interventions Applied To Patient

Direct Pressure

Indirect Pressure

Elevation

Dressing

Tourniquet

Haemostatic

Pelvic Binder

TXA Intervention

Primary Survey (C-SPINE)

No Injury Suspected

Injury Possible

Any high risk factors present (age greater than 65, paraesthesia, significant mechanism?

YESNO

C-Spine High Risk Factors (PATIENT TO BE IMMOBILISED)

Age Greater Than 65 Years

Paraesthesia

Significant Mechanism

C-Spine Low Risk Factors (PATIENT TO BE ASSESSED ROM)

Simple rear end collision,

Patient is in a sitting position

Patient Mobilised

Delayed Pain

No central neck pain

No spinal tenderness

C-Spine ROM AssessmentCan the patient rotate their neck 45 degrees?

YESNO

C-SPINE Cleared On Scene Using Canadian C-Spine Assessment ROM

C-Spine Interventions Applied To Patient

Hard Collar Applied

Scoop

Vacuum Mattress

Head Blocks

Neutral Alignment Maintained

Patient Asked To Remain Still

Primary Survey (AIRWAY CLEAR)

YESNO

Airway Obstructed Details

Airway Interventions Applied To Patient

Head tilt chin lift

Jaw Thrust

Back Slaps

Abdominal Thrusts

Chest Thrusts

OP Airway Inserted

NP Airway Inserted

Igel Inserted

Intubated

Needle Thoracentesis

Surgical Airway

Suction

Recovery Position

Use Of Forceps

Finger Sweep

Postural Drainage

1st Set Of Observations Time

Hour

Minutes

1st Set Initial Observations

Respiratory Rate

Oxygen Saturation

Pulse Rate

Peak Flow

Temp

Blood Pressure SYS/DYS

Blood Glucose (mmol/L)

Pupils

2nd Set Of Observations Time

Hour

Minutes

2nd Set Observations

Respiratory Rate

Oxygen Saturation

Pulse Rate

Peak Flow

Temp

Blood Pressure SYS/DYS

Blood Glucose (mmol/L)

Pupils

Would You Like To Add A Further Set Of Patient Observations

YESNO

3rd Set Of Observations Time

Hour

Minutes

3rd Set Observations

Respiratory Rate

Oxygen Saturation

Pulse Rate

Peak Flow

Temp

Blood Pressure SYS/DYS

Blood Glucose (mmol/L)

Pupils

Do you want to fill in patient details now or last?

Does The Patient Look Very Unwell Or Is NEWS Score 3 Or Above?

YESNO

Sepsis Screening (Is the patients history suggestive of infection?)Red Flag Screening

Yes, but source not obvious

Pneumonia/ likely chest source

Urinary Tract Infection

Abdominal pain or distension

Cellulitis/ septic arthritis/ infected wound

Device-related infection

Meningitis

Other Infection

Is One Sepsis Red Flag Present?All that apply

No red flags present

Responds only to voice or pain/ unresponsive

Systolic B.P ≤ 90 mmHg (or drop >40 from normal)

Heart rate > 130 per minute

Respiratory rate ≥ 25 per minute

Needs oxygen to keep SpO2 ≥92%

Non-blanching rash, mottled/ ashen/ cyanotic

Not passed urine in last 18 hours

Recent chemotherapy

RED FLAG SEPSIS SUSPECTED

Time-critical, immediate action is required!
Resuscitation:
Oxygen to maintain saturations >94% (88% in COPD)
Record lactate (if available)
250ml boluses of Sodium Chloride: max 250mls

Is Any Sepsis Amber Flag Present?All that apply

No amber flags present

Relatives concerned about mental status

Acute deterioration in functional ability

Immunosuppressed

Trauma or surgery within the last 3 weeks

Respiratory rate 21-24 or breathing hard

Systolic BP 91-100

Heart rate 91-130

Not passed urine 12-18 hours

Temperature is under 36C

Clinical signs of wound, device or skin infection

AMBER FLAG SEPSIS SUSPECTED

Transfer to hospital
Communicate likelihood of sepsis at handover

SEPSIS SCREENED NO RED OR AMBER FLAGS PRESENT

PMH (Past Medical History)Medical Conditions And Medications

HPC (History Of Presenting Complaint)* This field is required.What happened Where and how ?

PC (Presenting Complaint(s)* This field is required.Presenting Complaint(s) & Clinicians Impression

RX (Treatments & Interventions)* This field is required.Treatments and interventions provided by the clinician(s)

Fill In Patient Details

Take Me To Form

Details Already Completed

Care Pathway* This field is required.

Time At Hospital

Hour

Minutes

I the patient with capacity refused the treatment, Transport and or advice offered to me by the medical team and take full responsibility for my actions and decision.

Clear

Medic Who Provided Treatment(s)* This field is required.

Unique PCR Number* This field is required.Date/Time

Medic Signature

Clear

Confidential Patient Care Record

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