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Generic Patient Report Form

This document is a patient report form containing fields to document details of a patient including name, DOB, symptoms, treatment given, and details of lifeguards involved in an incident. It collects information such as condition, treatment, and handover of the patient.

Uploaded by

Essie Mohammed
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© © All Rights Reserved
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765 views

Generic Patient Report Form

This document is a patient report form containing fields to document details of a patient including name, DOB, symptoms, treatment given, and details of lifeguards involved in an incident. It collects information such as condition, treatment, and handover of the patient.

Uploaded by

Essie Mohammed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient Report Incident Report No.

PATIENT DETAILS (1 patient per form)


Name: Post Town: Postcode: Country:
D.O.B.: _ _ / _ _ / _ _ ❏ Male ❏ Female

PATIENT CONDITION (on initial examination)


Symptoms Level of Conciousness
 Disorientated  Alert
A Abrasion (Graze)  Faint  Voice (responds to)
B Burn  Fitting  Pain (responds to)
C Contusion (Bruise)  Hyperventilating  Unresponsive
D Dislocation  In Shock
# Fracture  Nauseated Temperature
H Haemorrhage  Pale  Hyperthermic
HC Heart Condition  Sweating  Normal
L Laceration  Weak  Hypothermic
O Other  Vomiting
P Pain
S Swelling Airway Breathing Circulation
SP Suspected Spinal  Clear  Present  Strong
 Partially Obstructed  Absent  Normal
 Obstructed  Weak

DETAILS OF TREATMENT GIVEN ALLERGIES / PAST MEDICAL HISTORY


 Rest  Cleaned
 Reassurance  Plaster
 Warmed  Ice Applied
 Cooled  Dressing Applied
 Raised Legs  AED
 Bag & Mask  Oxygen Therapy
 Manual Suction  Spinal Board / Collar
 Other*  None
* Give Details…

PATIENT RELEASE PATIENT HANDOVER


 No further action  Advised to attend doctor  Land Ambulance  Air Ambulance

Patient / Parent / Guardian Signature: Duty of Care handed over to:


 SAR / Ambulance  Relative
Declined Treatment   Friend Other:
Patient / Witness Name: Name:
Patient / Witness Signature: Signature:

DETAILS OF ALL LIFEGUARDS INVOLVED


Name Signature Paid / Vol (P & V)

All injuries that incapacitate a worker to be absent from or unable to do work that they would reasonably be expected to do as part of their normal work for more than 7 days, must be
kept recorded and reported to the HSE within 15 days of the incident. To report the incident go to www.hse.gov.uk/riddor and complete the appropriate online report form or call the
Incident Contact Centre on 0845 300 9923 (opening hours Monday to Friday 8.30am to 5.00pm)

DATA PROTECTION ACT 1998 Your personal information will be held by the issuing authority. It will be held in compliance with data protection legislation and will be used for the purpose of identifying training
needs and insurance liability. Where necessary it may be disclosed to Local Authorities and Lifesaving Organisations. This form is to be returned to the issuing authority
Founded 1955, Chief Patron: H.R.H. The Duke of Edinburgh K.G., K.T. A Company Limited by Guarantee not having a Share Capital. Company Reg No. 2678080. Registered in England and Scotland.
v2 07.12 Registered Office: 19 Southernhay West, Exeter EX1 1PJ. Charity No: 1015668. Scottish Charity No: SC042339. VAT Reg No 142 2439 93. © Surf Life Saving GB All Rights Reserved 2012.

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