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Emergency Record © 1996 - 2005 T-System, Inc. Circle or check affirmatives, backslash (\) negatives. TRIAGE ASSESSMENT EMERGENCY RECORD Patient Name: Adult Trauma V/S BP___________ HR_________ RR_________ Temp_______ Triage Level: 1 2 3 4 5 Time: TIME SEEN: ARRIVED BY WITH: LOCATION: Tetanus Immunization: UTD >5 years > 10years 2005 Flu Yes No 2005 Pneumovax Yes No LAST FOOD LAST DRINK HISTORIAN: patient spouse paramedics Current Meds: HPI chief complaint: ALLERGIES: occurred: where: PHYSICAL EXAM just PTA home school General Appearance __c-collar ( PTA / in ED ) / backboard today work street __no acute distress __mild / moderate / severe distress yesterday __alert __anxious / lethargic days ago HEAD __see diagram context: __no evidence of __Battle’s sign / Raccoon Eyes trauma NECK __vertebral point-tenderness __non-tender __muscle spasm / decreased ROM __painless ROM __pain on movement of neck __trachea midline location of pain / --right-- --left-- shldr hip shldr hip injuries: arm thigh arm thigh head face mouth elbow knee elbow knee neck chest abdomen f-arm leg f-arm leg back upper mid- lower wrist ankle wrist ankle hand foot hand foot radiating to R / L thigh / leg severity of pain: associated symptoms: EYES __unequal pupils R- ____mm L- ____mm lost consciousness / dazed __PERRL __subconjunctival hemorrhage mild duration: __EOMI remembers: ENT __hemotympanum moderate impact coming to hospital / shelter __nml external __clotted nasal blood seizure inspection __dental injury / malocclusion severe __no dental injury RESP / CVS __decreased breath sounds ROS trouble breathing / chest pain __chest non-tender __wheezing / rales loss feeling / power arms / legs nausea / vomiting __breath sounds nml __splinting / paradoxical movements loss of bladder function __heart sounds nml headache skin laceration ABDOMEN __tenderness / guarding / rebound double vision / hearing loss recent fever / illness __non-tender __mass / organomegaly __no organomegaly GENITAL / RECTAL __perineal hematoma SOCIAL HX recent ETOH smoker drug abuse __nml genital exam __blood at urethral meatus __nml vaginal exam __decreased rectal tone __nml rectal exam PAST HX negative __heme negative stool NEURO / PSYCH __confusion / disorientation __oriented x3 __EOM palsy / anisocoria __mood & affect nml __facial asymmetry __CN’s nml as tested __unsteady / ataxic gait __sensation & __sensory / motor deficit motor nml Reflexes SKIN __see diagram __intact __crepitus / diaphoresis __warm, dry T=Tenderness BACK __see diagram PtT=Point Tenderness __no CVA __vertebral point-tenderness S=Swelling E=Ecchymosis tenderness __CVA tenderness Lac=Laceration __no vertebral __muscle spasm / limited ROM A=Abrasion B=Burn tenderness (∅ =without m=mild mod=moderate EXTREMITIES __see diagram sv=severe) __atraumatic __bony point-tenderness Tsv = Tenderness on __pelvis stable __painful / unable to bear weight palpation (severe) __hips non-tender __pulse deficit __no pedal edema __nml ROM Joint Exam: __limited ROM / ligaments laxity / joint effusion PROGRESS: Time________ unchanged improved re-examined PROCEDURES: Has adequate resources Wound Description / Repair length________cm location Inadequate Resources __shelter __medication __food / water superficial *subcut. ^muscle linear stellate irregular Instructions / Resources Given clean contaminated moderately / *heavily __Discussed with Dr. at distal NVT: neuro & vascular status intact no tendon injury __Counseled pt / family regarding: diagnosis need for follow-up transfer anesthesia: local digital block _______mL lidoc 1% 2% epi / bicarb marcaine 0.25% 0.5% LET __food / water given prep: __other support Shur-Clens / Betadine / Hibiclens debrided irrigated / washed w/ saline minimal / *mod. / * / ^extensive CLINICAL IMPRESSION: minimal / mod. / *extensive undermined foreign material removed minimal / mod. / ^extensive partially completely ^wound margins revised minimal / mod. / *extensive wound explored repair: Wound closed with: wound adhesive / steri-strips SKIN- #_____ _____-0 nylon / prolene / staples *SUBCUT- #______ _____-0 vicryl *may indicate intermediate repair ^may indicate complex repair Discharge Instructions Discharge Meds __Rx given LAB DISPOSITION- home shelter admitted transferred CONDITION- unchanged improved stable X-RAY Tetanus Given: PROVIDER SIGNATURE- Multiple Trauma .
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