Ambulance Handover to Emergency Care Standard
Emergency care needs fast, effective sharing of information. When clinicians have access to the information they need, they can better ensure safe and high-quality care for patients. To facilitate this, The Professional Record Standards Body (PRSB) has developed a standard for the information that is shared when care is transferred from ambulances to emergency departments.
Current release
Version: V1.0 | |||
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Release date | November 2019 | ||
Next release date | TBD | ||
Next release type | Significant maintenance update | ||
The standard | |
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Full standard – PRSB viewer | Available with next release |
Full standard – Excel |  |
Full standard – Json | Available with next release |
Supporting documentation | Description/purpose |
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ISN status | DAPB application not submitted at this stage. |
 | This document includes general implementation guidance for all PRSB standards and detailed guidance, specific to the eDischarge Summary Standard. |
 | Describes the purpose, methodolgy and stakeholder engagement for developing the standard, along with the findings and recommendations for further work. |
 | Summarises the hazards which could result from implementing the standard. |
 | Details the potential hazards from implementing the standard with their risk rating and mitigation. |
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About this standard
The standard defines the information that should be transferred from an ambulance to an emergency department when or just prior to the patient being transferred.
The benefits of an implemented ambulance handover standard:
- A consistent set of information available to the emergency care professionals through their own record system.
- Improved patient safety as emergency care professionals will know what medications have been administered, what diagnostic tests have been done, whether the patient has any allergies and other important information obtained by the paramedics.
- Improved efficiency through better workflow, continuity of care, and pre-arrival streaming based on clinical information.
Clinical leadership was provided by clinicians from the Royal College of Emergency Medicine and the College of Paramedics (CoP). The standard has been developed with the support of professionals and patients.
Scope
For use with all transfers from ambulance to emergency departments or urgent care services.
Out of scope:
- Ambulance transport or transfers between hospitals.
- Post event messages to the person’s GP if the person is not conveyed by ambulance services.
Summary table
This summary table gives an overview of the information transferred. The conformance (Conf) column indicates if the item is M – Mandatory, must be included, R – Required if the information is available or O – Optional.
Open summary view table
| Ambulance handover to secondary care – Version 1 | ||
| Name | Conf | Description |
| Person demographics | R | The person’s details and contact information. |
| GP practice | R | Details of the person’s GP practice. |
| Legal information | R | Information about lasting power of attorney or deputies, mental capacity, deprivation of liberty of safeguards or mental health act status, and consent for information sharing |
| Safeguarding | R | The safeguarding details of the person. |
| Referrer Details | R | Details of the source of referral/contact for the ambulance |
| Individual requirements | R | The individual requirements of the person, covering reasonable adjustments, impairments and mobility |
| Health and care professional details | R | Name and details of health or care professional responsible pre-transfer and others present |
| Participation in research | R | Details of the person’s participation in research studies |
| Incident details | M | Details of ambulance incident including date/time, location, arrival and leaving time, time of arrival for handover, source of call, time of symtom onset. Mostly provided by the local system. |
| Injury | R | Details of the person’s injury and of any drugs or alcohol used by the person |
| Relevant past medical, surgical and mental health history | R | The record of the person’s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. |
| Presenting complaints or issues | M | The person’s chief complaint as assessed by the care professional, its acuity and other person reported problems and issues |
| Diagnoses | R | The clinical assessment by the ambulance of crew of the persons clinical situation at the conclusion of their treatment. This will be one of confirmed diagnosis, suspected diagnosis or chief complaint. |
| Clinical Summary | R | Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). |
| Treatments and interventions | R | Details of any treatments and interventions carried out |
| Social context | R | The social setting in which the person lives, such as their household, occupational history, and lifestyle factors. Also details of any dependents |
| Investigation results | R | Any investigation results |
| Observations | R | The record of essential physiological observations, using National Early Warning Score (NEWS2) where appropriate. |
| Assessments | R | Details of assessments completeted |
| Risks | R | Details of any risks related to the person including risk to self, to others, from others, or of infection |
| Allergies and adverse reactions | M | Details of any known allergies and adverse reactions, or statement of none known |
| Medications and medical devices | R | Details of any medications administered |
| Information and advice given | R | Information and advice given to the person |
| Person and carer concerns expectations and wishes | R | Details of the person and carer concerns, expectations and wishes, including an advance statement |
| Documents (including correspondence and images) | O | Details about documents and images related to the person. |
Further resources
- Standards explained
PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them. - Managing incorrect information in health records – IHRIM Good Practice Guidance
Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.
Endorsement
The standard is endorsed by:
- Association of Ambulance Chief Executives
- Chartered Society of Physiotherapists
- College of Paramedics
- Royal College of Emergency Medicine
- Royal College of Nursing
- Royal College of Obstetricians and Gynaecologists
- Royal College of Occupational Therapists
- Royal College of Physicians
- Royal College of Surgeons
- Royal College of Psychiatrists