"Ed Trauma Flow Sheet Template"

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DATE:
PATIENT IDENTIFICATION
ED TRAUMA FLOW SHEET
NOTIFICATION STATUS
MECHANISM OF INJURY
TIME OF NOTIFICATION
TIME
ROOM #
INJURY
ARRIVED
ASSAULT
COMMENTS: ___________________________________________________________
DATE
CODE YELLOW PAGED
BURN
___________________________
FRONT
BACK
OTHER:
CRUSH
COMMENTS: ___________________________________________________________
YES
NO
MODE OF ARRIVAL
DROWN
COMMENTS: ___________________________________________________________
POLICE
FALL
DISTANCE: ____________________________________________________________
AMBULANCE
WALK IN
GSW
LOCATION: ____________________________________________________________
AUTO
OTHER
MVC
BICYCLE
MOTORCYCLE
RESTRAINED
UNRESTRAINED
PRE - HOSPITAL CARE
HELMET
STEERING WHL
AIRBAG
EXTRICATED
NO HELMET
OXYGEN THERAPY
DRIVER
PEDESTRIAN
PASSENGER
EJECTED
NONE
STABBING
LOCATION: ____________________________________________________________
VIA
AT
LITERS
AIRWAY
ACLS
DEFIB
OTHER
DEATH ON SCENE
COMMENTS: _______________________________________________
NONE
EOA
ETT
ORAL
ECG
MEDS
IV'S
ESTIMATED TIME OF INJURY
BACKBOARD
CERVICAL COLLAR (TYPES)
DESCRIBED DETAILS
NONE
LONG
SHORT
SCOOP
OTHER
NONE
DRESSINGS
SPLINTS
NONE
NONE
TRAUMA TEAM RESPONSE
NAME
ARRIVED TIME/CALLED IN
ED PHYSICIAN
PRIEST
AGE
SEX
DOB
SURGEON
SIGNIFICANT PAST MEDICAL HISTORY
NSG SUPER
ED TRAUMA RN #1
ED TRAUMA RN #2
ANESTHESIA
MEDICINES
RADIOLOGY
RESPIRATORY THERAPY
CONSULT/DISCIPLINE
NAME
TIME CALLED
TIME ARRIVED
ALLERGIES
VALUABLES ON ARRIVAL
FAMILY NOTIFIED
LAST MEAL
TIME:
ARRIVAL:
LAST TETANUS
NAME:
LMP
UPT
TIME DONE
PART OF THE MEDICAL RECORD
PAGE 1 of 6
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
DATE:
PATIENT IDENTIFICATION
ED TRAUMA FLOW SHEET
NOTIFICATION STATUS
MECHANISM OF INJURY
TIME OF NOTIFICATION
TIME
ROOM #
INJURY
ARRIVED
ASSAULT
COMMENTS: ___________________________________________________________
DATE
CODE YELLOW PAGED
BURN
___________________________
FRONT
BACK
OTHER:
CRUSH
COMMENTS: ___________________________________________________________
YES
NO
MODE OF ARRIVAL
DROWN
COMMENTS: ___________________________________________________________
POLICE
FALL
DISTANCE: ____________________________________________________________
AMBULANCE
WALK IN
GSW
LOCATION: ____________________________________________________________
AUTO
OTHER
MVC
BICYCLE
MOTORCYCLE
RESTRAINED
UNRESTRAINED
PRE - HOSPITAL CARE
HELMET
STEERING WHL
AIRBAG
EXTRICATED
NO HELMET
OXYGEN THERAPY
DRIVER
PEDESTRIAN
PASSENGER
EJECTED
NONE
STABBING
LOCATION: ____________________________________________________________
VIA
AT
LITERS
AIRWAY
ACLS
DEFIB
OTHER
DEATH ON SCENE
COMMENTS: _______________________________________________
NONE
EOA
ETT
ORAL
ECG
MEDS
IV'S
ESTIMATED TIME OF INJURY
BACKBOARD
CERVICAL COLLAR (TYPES)
DESCRIBED DETAILS
NONE
LONG
SHORT
SCOOP
OTHER
NONE
DRESSINGS
SPLINTS
NONE
NONE
TRAUMA TEAM RESPONSE
NAME
ARRIVED TIME/CALLED IN
ED PHYSICIAN
PRIEST
AGE
SEX
DOB
SURGEON
SIGNIFICANT PAST MEDICAL HISTORY
NSG SUPER
ED TRAUMA RN #1
ED TRAUMA RN #2
ANESTHESIA
MEDICINES
RADIOLOGY
RESPIRATORY THERAPY
CONSULT/DISCIPLINE
NAME
TIME CALLED
TIME ARRIVED
ALLERGIES
VALUABLES ON ARRIVAL
FAMILY NOTIFIED
LAST MEAL
TIME:
ARRIVAL:
LAST TETANUS
NAME:
LMP
UPT
TIME DONE
PART OF THE MEDICAL RECORD
PAGE 1 of 6
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
D=Dilated
E=Equal
F=Fixed
P=Pinpoint
PUPIL LEGEND
1:
2:
3:
4:
5:
2
3
4
5
6
7
8
9
TIME
BP
PULSE:
RESP RATE
ARTERIAL BLOOD GASSES
TEMP
TIME
F l O
P h
p CO
p O
H C O
O
SAT
2
2
2
3
2
GCS
/
/
/
/
/
PUPILS L / R
6:
7:
8:
9:
10:
TIME
BP
PULSE:
RESP RATE
TEMP
MEDICATIONS
O
SAT
2
2
TIME
DRUG
DOSE
ROUTE
SITE
INITIALS
GCS
/
/
/
/
/
PUPILS L / R
11:
12:
13:
14:
15:
TIME
BP
PULSE:
RESP RATE
TEMP
O
SAT
2
2
GCS
/
/
/
/
/
PUPILS L / R
16:
17:
18:
19:
20:
TIME
BP
BLOOD PRODUCTS
PULSE:
TYPE & CROSS:
TIME SPECIMEN SENT:
RESP RATE
EMERGENCY 2 Units of PRBC:
TIME:
TEMP
TIME
TIME
O
SAT
UNIT #
P R B C W B
SITE
BY
TOTAL
2
2
UP
DOWN
GCS
/
/
/
/
/
PUPILS L / R
LABWORK
TIME
SENT
RESULT
BS
BUN
Cr
TIME
REQUEST
RESULTS
Na
Lat Cspine Portable
K
Complete Cspine Series
Cl
Chest (Upright) Portable
CO
2
Chest (Flat) Portable
Ca
Pelvis Portable
Phos
Lat Cspine Portable
Mg
Other:
CKO
Other:
PT
Other:
PTT
Other:
WBC
Other:
Hgb
Other:
Hct
PART OF THE MEDICAL RECORD
PAGE 2 of 6
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
INITIAL ASSESSMENT
AIRWAY PATENT:
YES
NO
SPONT. RESP. EFFORT
YES
NO
A
ARTIFICIAL AIRWAY:
NA
ORAL
NT
EOA
TRACH
ETT
TIME PLACED:
PTA
BY
CERVICAL COLLAR:
NONE
PTA
TYPE
TIME PLACED
BY
AIRWAY
TIME REMOVED
BY
BACKBOARD:
NONE
PTA
TYPE
TIME PLACED
BY
TIME REMOVED
BY
SPONTANEOUS RESP. EFFORT:
YES
N0
CHEST MOVEMENT:
NORMAL
SHALLOW
RETRACTIONS
PARADOXICAL
BREATH SOUNDS:
L
R
B
DIMINISHED
ABSENT
RALES
WHEEZE
PULSE OX
BREATHING
O THERAPY
TIME STARTED
2
NC
@
L/M
VENTILATION
NRBM
@
L/M
TV
F10
2
BVM
@
L/M
RATE
PEEP/CPAP
ETT
TIME INTUBATED
BY
SIZE TUBE
TAPED AT
PULSES
R
L
C
SKIN COLOR:
PINK
DUSTY
PALE
CYANOTIC
CARTOID
SKIN:
WARM
DRY
COOL
MOIST
BRACHIAL
CAP REFILL:
ABSENT
< 2 SEC
> 2 SEC
PALLOR
RADIAL
APICAL HEART TONES:
CLEAR
MUFFLED
FEMORAL
JVD:
ABSENT
PRESENT
POPLITEAL
CIRCULATION
CPR:
TIME STARTED
BY
DORSALIS
PEDIS
S=Strong
W=Weak
PUPILS:
D=Doppler
A=Absent
R
L
BRISK
D
2
3
4
5
6
7
8
9
SLUGGISH
NO RESPONSE
SIZE
LOC - ORIENTED X3:
PERSON
GLASCOW COMA SCALE INITIAL
REVISED COMA SCALE INITIAL
NEURO-
TIME
Spontaneously
4
4
-2
4
4
GLASCOW
LOGICAL
PLACE
To Speech
-3
3
3
EYES
COMA
EFFECTS
ALERT
To Pain
2
2
OPEN
TOTAL
ORIENTED X3
None
3 or less
1
1
0
0
SOMNOLENT
Oriented
89 mm Hg
5
5
4
4
UNCONSCIOUS
Confused
76 - 88 mm Hg
4
4
3
3
BEST
SYSTOLIC
ALERT
VERBAL
Inappropriate Sounds
50 - 75 mm Hg
3
3
2
2
VERBAL
BLOOD
EVENT RECALL
Incomprehensible
1 - 49 mm Hg
RESPONSE
2
2
PRESSURE
1
1
VERBAL
CONFUSED
None
No Pulse
1
1
0
0
TRANSIENT LOSS OF
Obeys Command
10 - 29 / Min
5
5
4
4
PAIN
CONSCIOUSNESS
Localizes Pain
5
5
29 / Min
3
3
BEST
RESPIR-
Withdraws to Pain
6 - 9 / Min
4
4
2
2
MOTOR
ATORY
UNCONSCIOUS
EXTREMITY MOVEMENT:
Flexes to Pain
1 - 5 / Min
3
3
1
1
RESPONSE
RATE
R ARM
Extends to Pain
None
YES
NO
2
2
0
0
DEFORMITY
YES
NO
None
1
1
R LEG
YES
NO
GLASCOW COMA
TOTAL
DEFORMITY
TOTAL
REVISED
YES
NO
Paralytic Agents
L ARM
YES
NO
TRAUMA
Y / N
Y / N
DEFORMITY
YES
NO
On Board?
SCORE
L ARM
Suspected
YES
NO
Y / N Y / N
Substance Abuse?
DEFORMITY
YES
NO
PART OF THE MEDICAL RECORD
PAGE 3 of 6
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
E
EXPOSE PATIENT
COMPLETELY
HEAD TO TOE
F
FAHRENHEIT
BLANKETS
WARMING LIGHTS
G
MONITOR
BP
BP
HEART
PRINTOUT
R ARM
L ARM
RATE
RATE
GET FULL SET
OF BP+HR:
(vs.) TIME
ORAL/RECTAL TEMPERATURE
Separate SHEET
OPEN CARDIAC
TIME BY
INITIAL OUTPUT
ELECTROCARDIOGRAM / 12 LEAD
MASSAGE
PERITONEAL LAVAGE
CODE BLUE
CHEST TUBE #1
SHEETS
SITE:
SIZE:
CHEST TUBE #2
INTERNAL DEFIB
SITE:
SIZE:
FOLEY SIZE
NG TUBE SIZE
CRIC
MONITOR STRIP
NEEDLE DECOMPRESSION
LARGE BORE IV
H
PERICARDIOCENTESIS
LARGE BORE IV
NORMAL / INTACT SKIN
CENTRAL LINE
GAUGE: __________________
A= ABRASION
L=
LACERATION
B= BURN
M=
AMPUTATING
HEAD
C= CLOSED/SUSPECTED
O=
OPEN FRACTURE
TO TOE
FRACTURE
P=
PAIN
D= DEFORMITY
S=
STABWOUND
E= ECCHYMOSIS
V=
AVULSION
G= GUNSHOT WOUND
Z=
OTHER: ___________________
BLEEDING
ABDOMEN:
VOMITING
DISTENDED
BOWEL SOUNDS
CSF -
NON-TENDER
TENDER
SOFT
FIRM
EARS
PELVIS:
STABL
STOOL GUAIC:
RECTAL TONE:
NOSE
UNSTABLE TO PALPITATION
PAIN TO PALPITATION
GENITOURINARY:
SPONT. VOID
INCONTINENT
URINE:
COLORLESS
YELLOW
RED
BROWN
UPT
CLOUDY
NONE
URINE DIP
VAGINAL BLEEDING:
NO
YES
PRIAPISM:
NO
YES
I
INSPECT THE BACK:
TIME
INSPECT BACK
LOG ROLL:
INJURIES
PART OF THE MEDICAL RECORD
PAGE 4 of 6
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
INTAKE
OUTPUT
IV# / AMT
SITE
SOLUTION
TIME UP
BY
TIME DOWN
TOTAL
TIME / AMOUNT
TIME / AMOUNT
URINE:
GASTRIC / LAVAGE:
L CHEST:
R CHEST:
EMESIS:
TOTAL:
TOTAL INTAKE AND OUTPUT
INTAKE:
OUTPUT:
IV:
FOLEY:
BLOOD:
GASTRIC:
ORAL:
CHEST TUBE:
OTHER:
OTHER:
OTHER:
OTHER:
TOTAL:
TOTAL:
MONITOR STRIP
DISPOSITION:
ADMITTED:
DX:___________________________________
ATTENDING:_______________________________
TIME ADMIT CALLED: ____________________________
ROOM #: __________________________________
TIME REPORT CALLED:___________________________
TO:_______________________________________
TIME LEFT ED: ______________________
O
RN
2
BELONGINGS: ________________________________________________________________________________________
TRANSFERRED:
TO:___________________________________
VIA: ______________________________________
BELONGINGS: ________________________________________________________________________________________
TIME LEFT ED: ___________________________________
TRANSFER FORM COMPLETED:______________
DEATH:
TIME OF DEATH:_________________________
PRONOUNCED BY: _________________________
TIME PMD NOTIFIED: _____________________
CODE BLUE SHEET COMPLETED: ___________________________
TIME CORONER NOTIFIED: ________________
SIGNED DEATH CERTIFICATE?
YES
NO
DONOR FORM COMPLETED:
YES
NO
WRTC NOTIFIED:
YES
NO
TIME BODY MOVED: _____________________
CORONER
MORGUE
POLICE/HOMICIDE:
TIME NOTIFIED: _____________________
TIME RESPONDED: ______________________
MD SIGNATURE: _________________________________
PRIMARY NURSE'S SIGNATURE /
DATE: ______________
TITLE: ___________________________________________________
PART OF THE MEDICAL RECORD
8850011 Rev 05/05
PAGE 5 of 6
ED Trauma Flow Sheet_EMERGENCY ROOM
Page of 6