Patient Report Form (LA4) NHS CONFIDENTIAL

CAD / Call Fleet M.I.

Event Date sign Patient No.
number number

Activation details Map Call Dispatch Arrive

RVP/ LAS response on scene 1st 2nd 3rd
Call signs
Police
given as Age M F U/K time Stand-off +
Location Officer ID
On Also on scene
Emergency En route
Scene First
Non responder Officer / T Leader
Emergency Dispatched by Arrive
Patient Other LAS VAS
Origin time HEMS/ Other NHS
Accepted by Delay code BASICS Ambulance Service Fire
OTher delay
Called Vehicle
by activation Cancelled call Time By (Initials)

Patient’s details Observations

Last name
Presenting complaint Allergies Known infectious
Y 12 Lead ECG
Time
First name Past medical history Medication Normal ECG
AVPU Inferior MI
Date of birth Age
Anterior MI
Incident time / onset of symptoms Resp rate
Lateral MI
Time
Male Female Race Resp depth Posterior MI
Date LBBB
Air O2 Air O2
NHS No. % O2 sats ST depression
Airway T wave changes only
Home Other abnormality
address Clear Peak flow
Partially obstructed Medication List
brought in brought in Inconclusive ECG
Obstructed CO2
Breathing Pulse Y FAST Unable to Affected
rate assess side Chest pain Shortness
Present Facial weakness (cardiac in origin) of breath
Postcode Pulse Unequal smile or obvious weakness Y N R L
Absent character Other symptoms T-LOC
/ pain (cardiac in origin)
Tel no. Complete a sentence Arm weakness Y N R L
in one breath Y N BP One arm drifts down or falls Palpitations
Next of Kin Unable to assess Speech
Circulation Colour
Word finding difficulties or slurred speech Y N N Asymptomatic
N
Relationship
B.mucosa cyanosed Y N Y Cannulation
Contact BM IV Size Time No touch technique
details Line 1 IO
Peripheral cyanosis Y N g Successful Y N By Placed in emergency
conditions Flush
Temp
GP Name Capillary refill > 2 sec Y N IV Size Time No touch technique
Line 2
Address Pain 0-10
Distal pulse
Other
Y N IO g Successful Y N By Placed in emergency
conditions Flush N
At scene Visited Phoned To visit Letter R L R L
Pupils size
Mental Health Team Sweating Y N Y Fluid and drug administration Drug bag
codes N
/ CPN / AMHP Pupils R L R L Code Name Amount Dose Route Time By
Contact Vomiting Y N reactive Y N Y N Y N Y N
details
Fitting Y N E V M E V M
Name of H.V.
/ Primary Carer Number of fits Mins GCS
Name of School Total Total
/ Nursery Burns %
ECG Initial rhythm
Patient Estimated rhythm
accompanied by blood loss

Continuation
Airway and Respiratory management
Y Airway adjunct ET successful SGA successful NCr NTh
Maintenance OP Y N By Y N By
NCr successful NTh successful
Postural Clearance NP ET
size
SGA
size Y N By Y N By
Head tilt Suction ET Time Time Time Time
Jaw thrust Manual SGA
N
Cardiac arrest, CPR, Defib, & ROSC
Y Arrest witnessed Cause of cardiac arrest Pre-LAS CPR Y N LAS CPR Y N
Time started
Y N Cardiac Trauma Effective
Time started By
Respiratory
Y N Total Controlled Drug Signed Witnessed
By other Other amount wasted
By crew
By LAS Defib Y N
Initial arrest rhythm Return of Recognition
Pre-LAS Defib Y N
Time of1st
LAS shock By
spontaneous Y N
respiration
Time Y Of Life Extinct
Time
On scene VF / VT
During Time Return Of Heart sounds absent Asystolic rhythm strip
removal Asystole started Number of
shocks Spontaneous Y N Time
Circulation Apnoeic Confirmed
In PEA
N N
Paediatric dead at
Ambulance By
electrodes used Y N ROSC sustained to hospital Y N Fixed dilated pupils Hospital

Injury = X ? Fracture = #
Burns = Pain =

Transporting
/ Left scene Pre-alert

Lifting and immobilisation Arrive Hospital/Destination Additional forms completed

Transport arrive AVPU
Clinical
Major Trauma
triage tool
positive
Y
Treatment before
LAS arrival Y N Mental capacity Y N
LA 3 LA 5
Continuation sheet Y X

Carry chair Trolley bed Handover Patient consent Capacity tool

Step obtained Y N used Y N LA 52 LA 277 Primary code
Ortho Carry sheet Hospital / facility name Patient
Mangar Elk Other Handover Physical disability Y Learning disability Y LA 279 LA 280 Main
Private address illness/Injury code
Splints Department / Ward Nurse Midwife Work Ambulance Personnel Secondary
Name Personnel No Status
illness/Injury code
Doctor Other Street
Collar Rescue board
KED / RED Destination code (suffix) Signature
GP Surgery 1 Attend Patient
Box / Vacuum not conveyed
Care home / referral code
Traction Pelvic splint
Police custody 2 Driver
Other Patient’s SPATS No patient code
property barcode Other public 3 Other
bag used
Patient Forced entry 4 Other Event complete
Tourniquet used Hospital No. undertaken Y
 Disclosure of Patient Details PRF CLINICAL SKILL LEVEL PAIN ASSESSMENT
Paramedic P
There is a legal requirement for all staff to maintain confidentiality in compliance with the Data Protection Act Team Leader L
(1998) and Access to Health Records Act (1980). 10
Student Paramedic 1 T
Student Paramedic 2 U Hurts worst
The white duplicate copy of the PRF must be handed to the receiving unit (or left with the patient if not conveyed). Student Paramedic 3 N 9
The original white TOP copy must be retained and submitted for archiving. EMT 1 1
EMT 2 2
8
The PRF or the information from that document may not be disclosed without the patient’s consent or a Declaration EMT 3 3
Form for Data User (Police) (LA414) being completed. Copies of the declaration form can be obtained from the EMT 4 4 Hurts whole lot
Trust intranet and when completed, must be faxed to the Operational Information and Archive Department. A&E Support S 7
Doctor D
PTS X
6
MENTAL CAPACITY ACT 2005 Hurts even more
5
The MCA (2005) provides a legal framework for acting and making decisions on behalf of individuals (over the age of 16) who lack the capacity to make
a particular decision for themselves. The underlying philosophy of the MCA is to ensure that any decision made, or action taken, on behalf of someone 4
who lacks the capacity to make the decision or act for themselves is made in their best interests. A person must be assumed to have capacity unless
it is established that they lack capacity. Hurts little more
3
A person may lack capacity if they are UNABLE to do any one or more of the following:
2
1. Comprehend the information relevant to the decision
2. Retain the information long enough to make a decision Hurts little bit
3. Use and weigh the information as part of the process of making the decision 1
4. Communicate the decision in any way
0 NO PAIN
Refer to LA5 for formal guidance on assessment of mental capacity.
Mental Capacity Act 2005: Code of Practice (2007) Crown copyright No hurt

Wong Baker Faces: Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s

essentials of Pediatric Nursing, ed. 7, St. Louis, 2005 p. 1259. Copyright,
Remember to submit 12 lead ECGs (NOT a rhythm trace) and ETCO2 traces with PRF. Write DATE, CAD, PRF NUMBER and Mosby. Colour Scale: McGrath et al, 1996.

CALLSIGN on printout.

Patient Non-Conveyance Checklist Yes No

Paediatrics
1. Is the patient refusing treatment/transport AGAINST clinical advice?
Any child under the age of 2 years MUST be
2. If ‘YES’ - Does the patient have capacity to refuse treatment/transport? conveyed to hospital, unless parent/guardian
declines against advice. Consider safeguarding
3. Have the following been completed and documented on the PRF? referral if a child under 2 years is not conveyed.

Two sets of patient observations (> 20 minutes apart) Any child under the age of 5 years must be
referred to a GP if not conveyed to hospital.
Details of any referral to an Appropriate Care Pathway/GP
(Including name of HCP/Service accepting referral and time)

If any of the above could not be completed, state reason______________________________________________________________________

4. Advice provided to patient/parent/guardian

Details of advice_____________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

5. Copy of PRF left with patient? If ‘No’, state reason___________________________________

6. Patient left in care of responsible person?

Details of responsible person (or reason why unable to leave patient in care) _____________________________________________________

___________________________________________________________________________________________________________________

Cases not requiring patient transport to hospital: Statement by Patient/Parent/Guardian

Following clinical assessment by the Ambulance crew, I have been advised that I/the patient do not require transport to hospital at this time or that referral to another
care pathway is appropriate. I understand the advice that I have received from the Ambulance crew and I agree with the plan proposed. I have received relevant
information and been advised of the action to take in the event of any deterioration/change in condition.
Patient/Parent/Guardian Name* (PRINT) _____________________________________ Signature__________________________________________________

Refusal of treatment or transport: Statement by the Patient/Parent/Guardian

Information and treatment options relating to my/the patient’s condition/injuries have been explained by the Ambulance Service. I understand the advice provided by
the ambulance crew and I understand the risks of refusing treatment or transport to a healthcare facility.
Patient/Parent/Guardian Name* (PRINT)_____________________________________ Signature__________________________________________________
(*delete as appropriate)

Refusal to wear a seat belt

I have been advised by the Ambulance crew that I am required to wear a seat belt to comply with the law and refuse to do so.
Name (PRINT)__________________________________________________________ Signature__________________________________________________
 Patient Report Form (LA4) NHS CONFIDENTIAL
CAD / Call Fleet M.I.
Event Date sign Patient No.
number number

Activation details Map Call Dispatch Arrive

RVP/ LAS response on scene 1st 2nd 3rd
Call signs
Police
given as Age M F U/K time Stand-off +
Location Officer ID
On Also on scene
Emergency En route
Scene First
Non responder Officer / T Leader
Emergency Dispatched by Arrive
Patient Other LAS VAS
Origin time HEMS/ Other NHS
Accepted by Delay code BASICS Ambulance Service Fire
OTher delay
Called Vehicle
by activation Cancelled call Time By (Initials)

Patient’s details Observations

Last name
Presenting complaint Allergies Known infectious
Y 12 Lead ECG
Time
First name Past medical history Medication Normal ECG
AVPU Inferior MI
Date of birth Age
Anterior MI
Incident time / onset of symptoms Resp rate
Lateral MI
Time
Male Female Race Resp depth Posterior MI
Date LBBB
Air O2 Air O2
NHS No. % O2 sats ST depression
Airway T wave changes only
Home Other abnormality
address Clear Peak flow
Partially obstructed Medication List
brought in brought in Inconclusive ECG
Obstructed CO2
Breathing Pulse Y FAST Unable to Affected
rate assess side Chest pain Shortness
Present Facial weakness (cardiac in origin) of breath
Postcode Pulse Unequal smile or obvious weakness Y N R L
Absent character Other symptoms T-LOC
/ pain (cardiac in origin)
Tel no. Complete a sentence Arm weakness Y N R L
in one breath Y N BP One arm drifts down or falls Palpitations
Next of Kin Unable to assess Speech
Circulation Colour
Word finding difficulties or slurred speech Y N N Asymptomatic
N
Relationship
B.mucosa cyanosed Y N Y Cannulation
Contact BM IV Size Time No touch technique
details Line 1 IO
Peripheral cyanosis Y N g Successful Y N By Placed in emergency
conditions Flush
Temp
GP Name Capillary refill > 2 sec Y N IV Size Time No touch technique
Line 2
Address Pain 0-10
Distal pulse
Other
Y N IO g Successful Y N By Placed in emergency
conditions Flush N
At scene Visited Phoned To visit Letter R L R L
Pupils size
Mental Health Team Sweating Y N Y Fluid and drug administration Drug bag
codes N
/ CPN / AMHP Pupils R L R L Code Name Amount Dose Route Time By
Contact Vomiting Y N reactive Y N Y N Y N Y N
details
Fitting Y N E V M E V M
Name of H.V.
/ Primary Carer Number of fits Mins GCS
Name of School Total Total
/ Nursery Burns %
ECG Initial rhythm
Patient Estimated rhythm
accompanied by blood loss

Continuation
Airway and Respiratory management
Y Airway adjunct ET successful SGA successful NCr NTh
Maintenance OP Y N By Y N By
NCr successful NTh successful
Postural Clearance NP ET
size
SGA
size Y N By Y N By
Head tilt Suction ET Time Time Time Time
Jaw thrust Manual SGA
N
Cardiac arrest, CPR, Defib, & ROSC
Y Arrest witnessed Cause of cardiac arrest Pre-LAS CPR Y N LAS CPR Y N
Time started
Y N Cardiac Trauma Effective
Time started By
Respiratory
Y N Total Controlled Drug Signed Witnessed
By other Other amount wasted
By crew
By LAS Defib Y N
Initial arrest rhythm Return of Recognition
Pre-LAS Defib Y N
Time of1st
LAS shock By
spontaneous Y N
respiration
Time Y Of Life Extinct
Time
On scene VF / VT
During Time Return Of Heart sounds absent Asystolic rhythm strip
removal Asystole started Number of
shocks Spontaneous Y N Time
Circulation Apnoeic Confirmed
In PEA
N N
Paediatric dead at
Ambulance By
electrodes used Y N ROSC sustained to hospital Y N Fixed dilated pupils Hospital

Injury = X ? Fracture = #
Burns = Pain =

Transporting
/ Left scene Pre-alert

Lifting and immobilisation Arrive Hospital/Destination Additional forms completed

Transport arrive AVPU
Clinical
Major Trauma
triage tool
positive
Y
Treatment before
LAS arrival Y N Mental capacity Y N
LA 3 LA 5
Continuation sheet Y X

Carry chair Trolley bed Handover Patient consent Capacity tool

Step obtained Y N used Y N LA 52 LA 277 Primary code
Ortho Carry sheet Hospital / facility name Patient
Mangar Elk Other Handover Physical disability Y Learning disability Y LA 279 LA 280 Main
Private address illness/Injury code
Splints Department / Ward Nurse Midwife Work Ambulance Personnel Secondary
Name Personnel No Status
illness/Injury code
Doctor Other Street
Collar Rescue board
KED / RED Destination code (suffix) Signature
GP Surgery 1 Attend Patient
Box / Vacuum not conveyed
Care home / referral code
Traction Pelvic splint
Police custody 2 Driver
Other Patient’s SPATS No patient code
property barcode Other public 3 Other
bag used
Patient Forced entry 4 Other Event complete
Tourniquet used Hospital No. undertaken Y
Use of your personal information

Personal information and details of your emergency treatment and care may be used for clinical audit and research purposes to ensure high levels of patient care.
The London Ambulance Service may also wish to contact you to ask you about the care you received using the details you have provided. Should you have any questions
regarding clinical audit and research conducted by the London Ambulance Service NHS Trust, or wish not to be contacted for clinical audit and research purposes, please
contact [email protected] or call 020 3069 0240. For more information visit:

www.londonambulance.nhs.uk/talking_with_us/use_your_personal_information.aspx#clinical

Ethnicity Codes
Z – 1 Patient was unresponsive or unconscious

A White British Z – 2 LAS Staff were unable to communicate with patient

B White Irish
Z – 3 Patient’s condition made it impossible to obtain ethnicity code
C White Any other white background
Z – 4 Patient declined to indicate ethnicity
D Mixed White & Black Caribbean
E Mixed White & Black African
F Mixed White & Asian
G Mixed Any other mixed background
H Asian or British Asian Indian
J Asian or British Asian Pakistani
K Asian or British Asian Bangladeshi
L Asian or British Asian Any other Asian background
M Black or Black British Caribbean
N Black or Black British African
P Black or Black British Any other Black background
R Other Ethnic groups Chinese
S Other Ethnic groups Any other Ethnic group

Z Do not wish to answer question

 Patient Report Form (LA4) NHS CONFIDENTIAL
CAD / Call Fleet M.I.
Event Date sign Patient No.
number number

Activation details Map

Location
Emergency
Non
Emergency

Origin time

Patient’s details Presenting complaint

Last name
First name
Date of birth Age
Incident time / onset of symptoms
Time
Male Female Race
Date
NHS No.
Home
address

Postcode
Tel no.

Next of Kin
Relationship
Contact
details

GP Name
Address
At scene Visited Phoned To visit Letter

Mental Health Team

/ CPN / AMHP
Contact
details

Name of H.V.
/ Primary Carer
Name of School
/ Nursery
Patient
accompanied by