EFAR Scotland — Patient Report Form
Incident Details
Date
Time of call
Event
Location
Patient encountered by
Responded to Incident
Patient self-presented
On scene time
Staff
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Incident description
Patient Details
First Name
Last Name
Preferred name
Provided
Unknown
Refused
Date of Birth
Provided
Unknown
Refused
Age
Sex
Male
Female
Other
Refused
Specify other sex
Address
Address Line 1
Address Line 2
City / Town
Postcode
Country
Provided
No Fixed Abode
Unknown
Refused
Phone number
Provided
Refused
Unknown
Parent / Guardian Details
Name
Relationship to patient
Contact number
Special Situations
Activity / situation
Select if applicable
Motorsport (4 Wheel)
Motorsport (2 Wheel)
Cycling
Running
Watersports
Equestrian
Winter Sports
Contact / Combat Sport
Other
Motorsport (4 Wheel)
Competition / Race Number
Helmet worn
No
Unknown
Harness worn
No
Unknown
Roll cage / rollover protection
No
Unknown
Head and neck restraint (HANS) worn
No
Unknown
Additional Notes
Motorsport (2 Wheel)
Competition / Race Number
Helmet worn
No
Unknown
Protective riding gear worn
No
Unknown
Back protector worn
No
Unknown
Additional Notes
Cycling
Race / Rider Number
Helmet Worn
No
Unknown
Protective equipment worn
No
Unknown
Additional Notes
Running
Race / Runner Number
Additional Notes
Watersports
Buoyancy aid / PFD worn
No
Unknown
Helmet worn
No
Unknown
Submersion involved
No
Unknown
Additional Notes
Equestrian
Rider / Competitor Number
Helmet worn
No
Unknown
Body protector worn
No
Unknown
Fall from horse
No
Unknown
Additional Notes
Winter Sports
Helmet worn
No
Unknown
Protective equipment worn
No
Unknown
Additional Notes
Contact / Combat Sport
Mouthguard worn
No
Unknown
Head protection worn
No
Unknown
Additional Notes
Other Special Situation
Activity / situation
Additional Notes
Consent
Patient has capacity?
Yes
No
Other
Consent provided by
Select
Patient
Parent / Guardian
Other
Reason consent was assumed / patient unable to provide consent
Select reason
Unconscious / unable to communicate
Not breathing / cardiac arrest
Immediate life-threatening emergency
Suspected intoxication / impaired capacity
Mental health / impaired capacity
Patient unable to understand / communicate a decision
Other
Consent for Examination
Gained
Refused
Benefits explained?
Yes
No
Risks explained?
Yes
No
Patient / consent giver understands?
Yes
No
Unknown
Reason / additional details
Consent for Treatment
Gained
Refused
Benefits explained?
Yes
No
Risks explained?
Yes
No
Patient / consent giver understands?
Yes
No
Unknown
Reason / additional details
Consent for Transport
Gained
Refused
Not Required
Benefits explained?
Yes
No
Risks explained?
Yes
No
Patient / consent giver understands?
Yes
No
Unknown
Reason / additional details
Past Medical History (PMHx)
Allergies?
Yes
No known allergies
Unknown / Unable to determine
List allergies
Medical conditions?
Yes
No known medical conditions
Unknown / Unable to determine
List medical conditions
Taking medication?
Yes
No regular medication
Unknown / Unable to determine
List medication
Last Oral Intake
Recorded
Unknown / Unable to determine
Time
Food / drink
Presenting Complaint (PC)
What is the main issue the patient needs help with right now?
History of Presenting Complaint (HxPC)
What led to this problem? (What happened, when/how long ago did it start, how has it changed over time?)
Priority symptoms / mechanisms (tick all that apply)
Medical / illness
Not breathing / cardiac arrest
Choking / airway problem
Chest pain
Breathing difficulty
Stroke symptoms
Seizure / convulsions
Overdose / poisoning
Allergic reaction / anaphylaxis
Abdominal pain
Fever / infection
Mental health crisis
Loss of consciousness
Trauma / injury
Major trauma
Head injury
Catastrophic haemorrhage
Penetrating injury
Suspected fracture
Suspected dislocation
Drowning / immersion
Fall
Minor injury
Obstetrics / gynae
Labour / imminent birth
Obstetric emergency
Gynaecology / early pregnancy
Other
When did the injury / presentation occur?
How long have symptoms been present?
Seconds
Minutes
Hours
Days
Weeks
Any similar episodes before?
Yes
No
Unknown
On Arrival (O/A)
ACVPU
A – Alert
C – Confusion (new)
V – Voice
P – Pain
U – Unresponsive
Pain score on arrival (0-10)
0
1
2
3
4
5
6
7
8
9
10
Position / activity you found them in
Sitting and talking
Lying flat, not moving
Tripod position
Standing / walking
Slumped in chair
On floor
Other
Who was already on scene?
Family / friends
Venue staff / security
Other
Was any treatment or first aid provided before EFAR arrival?
No
Yes
Unknown
What treatment / first aid was provided?
Epipen / adrenaline
Inhaler
Aspirin
GTN spray
Bystander Naloxone
Pain relief
Bystander CPR
AED / Defib
Bandage / dressing
Other
Who provided the treatment / first aid?
Security
Police
Bystander / Member of Public
Other Healthcare Professional
Other
On Examination (O/E)
Airway – what did you find?
Patent / normal
At Risk
Obstructed
Unable to self maintain
Unable to assess
Breathing – what did you find?
Normal
Fast (>20)
Slow (<10)
Noisy (wheeze / crackle)
SpO₂ < 94 % on air
Breathing Inadequate
Not Breathing
Circulation – what did you find?
Normal
Tachycardic (>100)
Bradycardic (<60)
Pale / mottled
Active bleeding
Cap refill >2 sec
No Pulse
Disability – what did you find?
Normal
Confused / agitated
In pain
Weak / non-moving limb
Slurred speech
Other neuro deficit
Reduced GCS
Unconscious
Exposure / Examination
Normal
C-Spine Injury
Head / face injury
Chest injury
Abdominal injury
Limb injury
External bleeding
Temp < 35 °C or > 38 °C
Injuries
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Additional Notes (elaborate on O/E findings)
Physiological Observations
+ Record New Observations
Management / Treatment Given
Catastrophic Haemorrhage Treatments
Tourniquet
Haemostatic
Packing
Traction splint
Pelvic binder
Other
Other
Tourniquet successful?
Yes
No
Haemostatic successful?
Yes
No
Airway Management / Interventions
Positioning
Head tilt / chin lift
Jaw thrust
Suction
Encourage cough
Back blows
Abdominal thrusts
OPA
NPA
i-gel / supraglottic airway
ET Tube
Other
Other airway intervention / adjunct
Positioning successful?
Yes
No
Head tilt / chin lift successful?
Yes
No
Jaw thrust successful?
Yes
No
Suction successful?
Yes
No
Encourage cough successful?
Yes
No
Back blows successful?
Yes
No
OPA size
Select size
000
00
0
1
1.5
2
3
4
5
OPA successful?
Yes
No
NPA size
Select size
4 mm
5 mm
6 mm
7 mm
8 mm
9 mm
NPA successful?
Yes
No
i-gel size / colour
Select size
1 – Pink
1.5 – Light blue
2 – Grey
2.5 – White
3 – Yellow
4 – Green
5 – Orange
i-gel / supraglottic airway successful?
Yes
No
ET Tube size
Select size
2.5 mm
3.0 mm
3.5 mm
4.0 mm
4.5 mm
5.0 mm
5.5 mm
6.0 mm
6.5 mm
7.0 mm
7.5 mm
8.0 mm
8.5 mm
9.0 mm
ET Tube successful?
Yes
No
Other airway intervention successful?
Yes
No
Breathing Treatments
BVM
Chest seal
Needle chest decompression
Nebuliser
Inhaler
Other
Chest seal successful?
Yes
No
Needle chest decompression successful?
Yes
No
Other
C-Spine Treatments
Manual (Crew)
Manual (Bystander/Public)
Collar
KED
Scoop
Board
Other
Other
Injury / Wound Management
Wound / bleeding treatment
Burn treatment
Bite / sting treatment
Splinting
Wound / bleeding treatment provided
Direct pressure
Wound cleaned
Dressing applied
Bandage applied
Steri-Strips
Wound glue
Foreign body removed
Foreign body secured
Burn treatment provided
Cooling commenced / continued
Clothing / jewellery removed
Burn covered
Burn dressing applied
Bite / sting treatment provided
Wound cleaned
Sting removed
Cold pack / cooling
Other Treatments
Reassurance / calming
Positioning (recovery/semi-recumbent)
IV Access
IO Access
ECG
CPR / defib
Labour / delivery care
Gynaecology / early pregnancy
CPR / Defib – OHCA Details
Arrest witnessed?
Yes
No
Unknown
Bystander CPR prior to arrival?
Yes
No
Unknown
Bystander CPR effective?
Yes
No
Unknown
AED applied before EFAR arrival?
Yes
No
Unknown
Downtime (minutes)
Number of shocks given
Initial rhythm
VF / pVT
PEA
Asystole
Unknown
Time CPR commenced
Time first shock
ROSC achieved?
Yes
No
ROSC time
Resuscitation ongoing on transport?
Yes
No
Resuscitation stopped / not started?
Yes
No
Time resuscitation stopped
Reason for stopping
ROSC achieved
No ROSC / clinical decision
Signs unequivocal with death
DNACPR / advance decision
Registered HCP decision
Other
Decision made by
Select person
Ambulance Service Clinician
Ambulance Service Doctor
BASICS Clinician / Doctor
Hospital Clinician / Doctor
Police
Other Healthcare Professional
Other
Name
Witness
Select witness
Ambulance Service Clinician
Ambulance Service Doctor
BASICS Clinician / Doctor
Hospital Clinician / Doctor
Police
Other Healthcare Professional
Other
Name
Additional stopping / resuscitation notes
Additional OHCA notes
Labour / Delivery Care Details
Pregnancy known / suspected?
Yes
No
Unknown
Gestation (weeks)
Estimated due date
First birth?
Yes
No
Unknown
Number of pregnancies (Gravida)
Number of births (Parity)
Multiple pregnancy?
Yes
No
Unknown
How many babies?
2 - Twins
3 - Triplets
4+
Labour / contractions started?
Yes
No
Unknown
Contraction interval (minutes)
Contraction duration (seconds)
Membranes ruptured / waters broken?
Yes
No
Unknown
Time membranes ruptured
Liquor
Clear
Meconium stained
Blood stained
Unknown
Urge to push / bearing down?
Yes
No
Unknown
Crowning / birth imminent?
Yes
No
Unknown
Presentation
Head first
Breech
Foot first
Hand first
Other
Unknown
Other presentation details
Birth occurred?
Yes
No
Unknown
Obstetric Emergencies / Delivery Complications?
Yes
No
Obstetric Emergencies / Delivery Complications
Antepartum haemorrhage
Postpartum haemorrhage / significant bleeding after birth
Pre-eclampsia / eclampsia / seizure in pregnancy
Maternal collapse / peri-arrest
Shoulder dystocia
Cord prolapse
Retained placenta / placental problem
Suspected uterine inversion
Suspected maternal sepsis / infection
Reduced / absent fetal movements
Preterm labour / imminent preterm birth
Other delivery complication
Other delivery complication details
Treatment / Care
Supported normal vaginal birth
Positioning / comfort measures
Pads / absorbent materials used and bleeding monitored
Controlled delivery of head
Newborn dried / warmed / stimulated
SD Management: McRoberts position
SD Management: Suprapubic pressure
SD Management: Positioning all fours
PPH Management: Uterine/fundal massage
PPH Management: Bimanual uterine compression
Breech Management: Positioning all fours
Breech Management: Positioning semi-recumbent
Breech Management: Manual pressure
Breech Management: Manual / assisted birthing
Breech Management: Manual rotation of baby
Seizure / convulsion management
Perineal protection / assessment
Other labour / delivery treatment
Other labour / delivery treatment
Additional labour / delivery notes
Gynaecology / Early Pregnancy Details
Heavy vaginal bleeding
Severe pelvic / lower abdominal pain
Suspected ectopic pregnancy
Suspected miscarriage / pregnancy loss
Suspected ovarian / adnexal emergency
Other gynaecological emergency
Other gynaecological emergency details
Pregnancy known / suspected?
Yes
No
Unknown
Gestation (weeks)
Estimated due date
Pregnancy test / result (if relevant)
Positive
Negative
Not performed
Unknown
Previous pregnancy / birth?
Yes
No
Unknown
Number of pregnancies (Gravida)
Number of births (Parity)
Gynaecology / early pregnancy details
Additional management notes
Medications / Drugs
Medication / Drug Administration
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Incident Details / Narrative
Tell the story of this incident from start to finish - what happened, how you managed it, and the outcome
Escalation
Advised to Attend ED / A&E
Hospital Transfer (Self)
Hospital Transfer (EFAR)
Ambulance Service
Police
Safeguarding Concerns
Advised to Attend ED / A&E
Reason
Did the patient attend ED / A&E?
Yes
No
Unknown
Hospital Transfer (Self)
Reason
Method of transport
Select method
Taxi / Private Hire
Friend / Family
Own Vehicle
Public Transport
Event Transport
Walking
Other
Other method
Hospital Transfer (EFAR)
Reason
Blue Lights Active?
Ambulance Service
Reason
Time of Call
Called by
Select who made the call
Medical Manager
Controller
Event Organiser
Bystander/Public
Outcome
Police
Reason
Time of Call
Called by
Select who made the call
Medical Manager
Controller
Event Organiser
Bystander/Public
Outcome
Incident Number
Safeguarding Concerns
Complete EFAR Safeguarding Concern Report Form
Details
Refusal / Declined Care Documentation
Refusal recorded
Patient / Guardian / Carer
Patient / Consent Giver Name
Signature
Clear signature
Date
Patient / guardian / carer declined to sign
EFAR Staff Witness
Staff member
Select staff member
Second staff member (if present)
Select staff member
Date
Additional refusal / discussion notes
Discharge Outcome
Discharge time
Discharge outcome
-- Select outcome --
Into care of self
Into care of self after refusal
Into care of friend
Into care of family/relative
Into care of Police
Into care of Ambulance Service
Into care of Hospital / Emergency Department
No Patient Found
No outcome required
Patient Deceased
Other
Specify other discharge outcome
Incident Number
Receiving Hospital
Advice given
GENERATE REPORT
GENERATE PATIENT / HOSPITAL COPY
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