ED_NURSE_ENCOUNTER
======
PATIENT NAME: |PATIENT NAME| DOB: |PATIENT DATE OF BIRTH| MR # |PATIENT HRCN|
======
{FLD:GPA-N-ED-10}
CLINIC: EMERGENCY DEPARTMENT
VISIT TYPE: ED NURSING
DATE OF VISIT: |VISIT DATE|
ASSESSMENT DATE/TIME:{FLD:DATE & TIME2}
SOURCE OF INFORMATION: {FLD:ED HISTORIAN1} {FLD:TEXT (1-20)}
PATIENT IDENTITY CONFIRMED BY 2 IDENTIFIERS: {FLD:OCA PT ID} {FLD:GEN TEXT 40}
======
SUBJECTIVE
======
|V CHIEF COMPLAINT| {FLD:TEXT 60}
======
OBJECTIVE
======
ALLERGIES: |ALLERGIES/ADR|
======
IMMUNIZATION STATUS:
|IMMUNIZATIONS DUE|
|LAST TD|
|LAST TDAP|
======
VITAL SIGNS:
Last Temp: |LAST TEMPERATURE|
Last Pulse: |LAST PULSE|
Last RR: |LAST RESPIRATION|
Last BP: |LAST BP|
Last O2 Sat: |LAST O2|
|LAST HT WITH DATE|
Page 1 ED_NURSE_ENCOUNTER|LAST WT WITH DATE|
======
MEDICATIONS:
|ACTIVE MEDICATIONS|
======
PAIN ASSESSMENT:
======
PAIN ASSESSMENT:
Pain Scale Used: {FLD:RSB ED NURSING PAIN SCALE1}
Pain Score: |LAST PAIN|
Unable to assess: {FLD:TEXT BOX 40 CHARACTERS}
Location:
{FLD:TEXT (1-40 CHAR)}
Duration:
{FLD:NUM 0-100} {FLD:RBH DURATION OF PAIN1}
Quality:
{FLD:RBH QUALITY PAIN1}{FLD:TEXT (1-40 CHAR)}
Timing:
{FLD:RBH TIMING OF PAIN1}
======
FALL ASSESSMENT:
Patient was identified as a fall risk by the Triage Nurse: {FLD:YES AND NO3}
Fall assessment tool
1. History of falling (immediate or previous): {FLD:SFSU HX OF FALL}
2. Secondary diagnosis(>/=2 medical diagnoses in chart):{FLD:SFSU SECONDARY DX}
3. Ambulatory Aid: {FLD:SFSU AMBULATORY AID1}
4. IV/Heparin Lock: {FLD:SFSU IV HEPARIN LOCK}
5. Gait/Transfer: {FLD:SFSU GAIT TRANSFER1}
6. Mental Status: {FLD:SFSU MENTAL STATUS1}
Total Score: {FLD:GEN TEXT 10}
Level of risk: {FLD:RBH MOR FALL HI RISK1}
======
ASSESSMENT - PRIMARY
======
{FLD:PR ER BED RAILS UP}
NEURO:
AVPU level of consciousness:
(If score below A-Alert, complete GCS)
{FLD:RBH AVPU}
Pupils: {FLD:RBH ED PUPIL}
Glasgow:
Glasgow Coma Scale:
Eye opening reponse: {FLD:NURS NEURO AROUSAL11}
Best verbal response: {FLD:F NUR NEURO VERBAL1}
Best motor response: {FLD:F NUR NEURO MOTOR1}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES}
Score: 15-13 Minor Brain Injury
9-12 Moderate Brain Injury
<8 Severe Brain Injury
Pupils: {FLD:RBH ED PUPIL}
Peds 2-5 y/o Glasgow Coma Scale
Eyes Open: {FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE EYE OPENING EYE OPEN}
Verbal:{FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE VERBAL RESPONSE }
Motor:{FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE MOTOR RESPONSE}
{FLD:PR ER PEDS GLASGOW COMA READ SCALE}
Page 6 ED_NURSE_ENCOUNTERTotal Score: {FLD:GEN TEXT 5 SPACES1}
{FLD:WORD PROCESSING BOX1}
Infant Glascow Coma Scale:
Eye opening reponse: {FLD:NURS GCS INFANT AROUSAL}
Best verbal response: {FLD:NURS GCS INFANT VERBAL}
Best motor response: {FLD:NURS GCS INFANT MOTOR}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES}
Score: 15-13 Minor Brain Injury
9-12 Moderate Brain Injury
<8 Severe Brain Injury
Pupils: {FLD:RBH ED PUPIL}
AIRWAY:
Patent, unobstructed airway
Abnormal airway
Airway obstructed - {FLD:WBH ER 1}
Trachea: {FLD:IHS ER TRACHEA}
Neck Veins: {FLD:IHS ER NECK VEINS}
Edema of Neck: {FLD:GEN YES/NO RADIO NO}{FLD:TEXT (1-40 CHAR)}
BREATHING:
Normal, non-labored, clear bilaterally. {FLD:TEXT (1-40 CHAR)}
Abnormal breathing:
Effort: {FLD:RBH EFFORT}
Sounds: {FLD:RBH SOUNDS} {FLD:TEXT (1-40 CHAR)}
CARDIOVASCULAR:
Heart rhythm/sounds: {FLD:NURS PULSE12}
Skin color: {FLD:RBH NUR COLOR1}
Capillary refill: {FLD:NURS CARDIO CAP REFILL3}
Nail bed color: {FLD:F NUR COLOR1}{FLD:GEN TEXT BOX 15}
Edema: {FLD:RBH NUR EDEMA} {FLD:TEXT (1-40 CHAR)}
GENITOURNIARY:
Symptoms: {FLD:CIH ROS URINARY2} {FLD:TEXT (1-40 CHAR)}
REPRODUCTIVE:
Gender: Female
|LMP2-BRIEF| {FLD:GEN DATE1}{FLD:N/A1}
Pregnant?: No
Pregnant?: Yes
Estimated due date: {FLD:GEN DATE1}
Gender: Male
Denies any reproductive/sexual health issues
C/O of reproductive/sexual health issues: {FLD:TEXT (1-40 CHAR)}
GASTROINTESTINAL:
{FLD:IHS ER ABDOMEN1}
Bowel Sounds: {FLD:IHS ER BOWEL SOUNDS} {FLD:RBH BOWEL SOUNDS2}
Last Bowel Movement:{FLD:DATE ONLY} {FLD:TEXT (1-40 CHAR)}
EXTREMITIES:
Uniform in appearance, equal grip and strength, full ROM bilaterally, no
injuries.
Abnormal Findings: {FLD:RBH EXTREMETIES}{FLD:WORD 1 LINE}
SKIN: {FLD:IHS PE SKIN8}
SKIN:{FLD:MHC SIGNIFICANT FINDINGS}{FLD:IHS WORD PROC NARROW INDENT}
Wound Exam:
WOUND DESCRIPTION:
LOCATION OF WOUND: {FLD:RIGHT/LEFT11} {FLD:TEXT-30}
SHAPE: {FLD:WBH WOUND SHAPE}
SIZE: {FLD:GEN TEXT 5 SPACES12} {FLD:WBH CM MM} by {FLD:GEN TEXT 5 SPACES12}{FLD:WBH CM MM}
DEPTH: {FLD:WBH WOUND DEPTH11}
HEALTH OF TISSUE: {FLD:WBH WOUND HEALTH111}
Page 12 ED_NURSE_ENCOUNTERDRAINAGE:{FLD:WBH DRAINAGE1}{FLD:TEXT-20111}
{FLD:GEN WORD INDENT 4}
WOUND REPAIR:
Wound was: {FLD:PR ER WOUND REPAIR11}
Repaired with {FLD:PR ER WND CLOSURE1}
Site: {FLD:TEXT (1-10 CHAR)2}
Size: {FLD:TEXT (1-10 CHAR)2}cm
Width: {FLD:TEXT (1-10 CHAR)2}cm
Depth: {FLD:TEXT (1-10 CHAR)2}cm
{FLD:GEN WORD INDENT 4}
***ABOVE INFORMATION IS ALSO REQUIRED FOR WOUND DEBRIBEMENT***
Please describe the debribement in detail
(ie; instrument used, size, location, grannulation...)
WOUND DEBRIDEMENT DESCRIPTION:
{FLD:GEN WORD INDENT 4}
****Clinical Institute Withdrawl Assessment For Alcohol Scale****
Date and Time of Assessment: {FLD:DATE & TIME1}
Pulse/Heart Rate Taken for one minute: {FLD:TEXT - 5}
Blood Pressure: {FLD:TEXT 7}
NAUSEA AND VOMITING
Ask Do you feel sick to you stomach? Have you vomited? Observation.
{FLD:PR ETOH N/V}{FLD:TEXT (1-40 CHAR)}
AUDITORY DISTURBANCES
Ask are you more aware of sounds around you? Are they harsh? Do they frighten you?
Are you hearing anything that is disturbing to you? Are you hearing things you know are
not there? Observation.
{FLD:PR ETOH AUDITORY}
HEADACHE, FULLNESS IN HEAD
Ask Does your head feel different? Does it feel like there is a band around your
head? DO NOT rate for dizziness or lightheadedness. Otherwise, rate severity.
{FLD:PR ETOH HEAD}
TACTILE DISTURBANCES
Ask Have you had any itching, pins and needles sensations, burning, or numbness, or do
you feel like bugs are crawling on or under you skin?
Observation.
{FLD:PR ETOH TACTILE}
PAROXYSMAL SWEATS
Observation.
{FLD:PR ETOH PAROXYSMAL}{FLD:TEXT (1-40 CHAR)}
AGITATION
Observation.
{FLD:PR ETOH AGITATION} {FLD:TEXT (1-40 CHAR)}
TREMOR
Arms extended and fingers spread apart.
Observation.
{FLD:PR ETOH TREMOR} {FLD:TEXT (1-40 CHAR)}
VISUAL DISTURBANCES
Ask Does the light apear to be too bright? Is its color different? Does it hurt your
eyes? Are you seeing anything that is disturbing to you? Are you seeing thing you know
are not there?
Observation.
{FLD:PR ETHO VISUAL}
Page 14 ED_NURSE_ENCOUNTERORIENTATION AND CLOUDING OF SENSORIUM
Ask What day is this? Where are you? Who am I?
Observation.
{FLD:PR ETHO ORIENTATION}
ANXIETY
Ask Do you feel nervous?
Observation.
{FLD:PR ETOH ANXIETY}
Total CIWA-AR Score: {FLD:TEXT - 5}
Maximum possible score is 67
Tool to assess the severity of alcohol withdrawl.
Absent or very mild: less than or equal to 8 points.
Mild: =9 to 14 points.
Moderate: =15 to 20 points.
Severe: Greater than 20 points.
Those with a score of less than 10 do not usually need additional medications.
Adapted from Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of
alcohol withdrawl: the revised clinical institute withdrawl assessment for alcohol scale
(CIWA-Ar). Br J Addict. 1989;84(11):1357.
IV ACCESS:
IV CARE:
{FLD:RBH IV CARE}
{FLD:EDIT 40/240}
IV Insertion:
Date/Time of insertion: {FLD:DATE & TIME2}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE21}{FLD:GEN TEXT BOX}
Type: {FLD:NURS IV TYPE121}
Size: {FLD:NUR ANGIOCATH SIZES21}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
Date/Time of insertion: {FLD:DATE & TIME2}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE21}{FLD:GEN TEXT BOX}
Type: {FLD:NURS IV TYPE121}
Size: {FLD:NUR ANGIOCATH SIZES21}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
{FLD:IHS CLICK HERE}{FLD:WORD PROCESSING 50/2}
IV Discontinuation:
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE112}{FLD:GEN TEXT BOX}
Date/Time discontinued: {FLD:DATE & TIME2}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE112}{FLD:GEN TEXT BOX}
Date/Time discontinued: {FLD:DATE & TIME2}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
CARDIAC MONITORING:
Date/Time of monitoring: {FLD:DATE & TIME2}
EKG:
Date/Time completed: {FLD:DATE & TIME2}
Type: 12 lead
OXYGENATION:
Oxygen Initiated:
Date/Time initiated: {FLD:DATE & TIME2}
O2 at {FLD:NUM 1-101}L/Min via {FLD:RBH O2 TYPE}
Oxygen Discontinued:
Date/Time discontinued: {FLD:DATE & TIME2}
WOUND CARE/ASSESSMENT:
Date of injury: {FLD:DATE ONLY}
Location: {FLD:RIGHT/LEFT11} {FLD:TEXT-30}
Shape: {FLD:WBH WOUND SHAPE}
Size: {FLD:GEN TEXT 5 SPACES12} {FLD:WBH CM MM} by {FLD:GEN TEXT 5 SPACES12}{FLD:WBH CM MM}
Dressing: {FLD:EDIT 40/240}
CATHETERIZATION
Inserted foley: {FLD:DATE/TIME}
Size: {FLD:GEN TEXT 5 SPACES11} F Return: {FLD:GEN TEXT BOX 10 SPACES}
mLs water in balloon: {FLD:GEN TEXT BOX 10 SPACES}
Secured: {FLD:YES / NO} to {FLD:TEXT (1-40 CHAR)}
Description: {FLD:GEN WORD PROCESSING}
In/Out straight catheter done.
Time done: {FLD:DATE/TIME}
Reason: {FLD:GEN TEXT BOX LONG41}
Volume Out: {FLD:GEN TEXT 5 SPACES11} mls
{FLD:GEN OTHER}{FLD:GEN WORD PROCESSING}
Patient tolerated procedure: {FLD:PT TOLERATED}{FLD:WORD PROCESSING - 2 LINES}
PROVIDER ASSISTANCE:
Assistance to Provider: {FLD:RBH ASSISTANCE}
{FLD:EDIT 40/240}
TEST/EXAMS/TREATMENTS:
Pt to Radiology for: {FLD:RBH EXAM }{FLD:TEXT 45}
Specimen to Lab: {FLD:RBH TO LAB}
NEURO:
AVPU level of consciousness:
(If score below A-Alert, complete GCS)
{FLD:RBH AVPU}
Pupils: {FLD:RBH ED PUPIL}
Glasgow:
Glasgow Coma Scale:
Eye opening reponse: {FLD:NURS NEURO AROUSAL11}
Best verbal response: {FLD:F NUR NEURO VERBAL1}
Best motor response: {FLD:F NUR NEURO MOTOR1}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES}
Score: 15-13 Minor Brain Injury
9-12 Moderate Brain Injury
<8 Severe Brain Injury
Pupils: {FLD:RBH ED PUPIL}
Peds 2-5 y/o Glasgow Coma Scale
Eyes Open: {FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE EYE OPENING EYE OPEN}
Verbal:{FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE VERBAL RESPONSE }
Motor:{FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE MOTOR RESPONSE}
{FLD:PR ER PEDS GLASGOW COMA READ SCALE}
Total Score: {FLD:GEN TEXT 5 SPACES1}
{FLD:WORD PROCESSING BOX1}
Infant Glascow Coma Scale:
Eye opening reponse: {FLD:NURS GCS INFANT AROUSAL}
Best verbal response: {FLD:NURS GCS INFANT VERBAL}
Best motor response: {FLD:NURS GCS INFANT MOTOR}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES}
Score: 15-13 Minor Brain Injury
9-12 Moderate Brain Injury
<8 Severe Brain Injury
Pupils: {FLD:RBH ED PUPIL}
======
INTERVENTIONS {FLD:GPA-N-ED-4}
======
IV ACCESS:
IV CARE:
{FLD:RBH IV CARE}
{FLD:EDIT 40/240}
IV Insertion:
Date/Time of insertion: {FLD:DATE & TIME2}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE21}{FLD:GEN TEXT BOX}
Type: {FLD:NURS IV TYPE1}
Size: {FLD:NUR ANGIOCATH SIZES21}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
Date/Time of insertion: {FLD:DATE & TIME2}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE21}{FLD:GEN TEXT BOX}
Type: {FLD:NURS IV TYPE1}
Size: {FLD:NUR ANGIOCATH SIZES21}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
{FLD:IHS CLICK HERE}{FLD:WORD PROCESSING 50/2}
IV Discontinuation:
======
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE11}{FLD:GEN TEXT BOX}
Date/Time discontinued: {FLD:DATE & TIME2}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE11}{FLD:GEN TEXT BOX}
Date/Time discontinued: {FLD:DATE & TIME2}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
CARDIAC MONITORING:
Date/Time of monitoring: {FLD:DATE & TIME2}
EKG:
Date/Time completed: {FLD:DATE & TIME2}
Type: 12 lead
OXYGENATION:
Oxygen Initiated:
Date/Time initiated: {FLD:DATE & TIME2}
O2 at {FLD:NUM 1-10}L/Min via {FLD:RBH O2 TYPE}
Page 26 ED_NURSE_ENCOUNTEROxygen Discontinued:
Date/Time discontinued: {FLD:DATE & TIME2}
WOUND CARE/ASSESSMENT:
Date of injury: {FLD:DATE ONLY}
Location: {FLD:RIGHT/LEFT1} {FLD:TEXT-30}
Shape: {FLD:WBH WOUND SHAPE}
Size: {FLD:GEN TEXT 5 SPACES} {FLD:WBH CM MM} by {FLD:GEN TEXT 5 SPACES}{FLD:WBH CM MM}
Dressing: {FLD:EDIT 40/240}
CATHETERIZATION
Inserted foley: {FLD:DATE/TIME}
Size: {FLD:GEN TEXT 5 SPACES1} F Return: {FLD:GEN TEXT BOX 10 SPACES}
mLs water in balloon: {FLD:GEN TEXT BOX 10 SPACES}
Secured: {FLD:YES / NO} to {FLD:TEXT (1-40 CHAR)}
Description: {FLD:GEN WORD PROCESSING}
In/Out straight catheter done.
Time done: {FLD:DATE/TIME}
Reason: {FLD:GEN TEXT BOX LONG41}
Volume Out: {FLD:GEN TEXT 5 SPACES1} mls
{FLD:GEN OTHER}{FLD:GEN WORD PROCESSING}
Patient tolerated procedure: {FLD:PT TOLERATED}{FLD:WORD PROCESSING - 2 LINES}
PROVIDER ASSISTANCE:
Assistance to Provider: {FLD:RBH ASSISTANCE}
{FLD:EDIT 40/240}
TEST/EXAMS/TREATMENTS:
Pt to Radiology for: {FLD:RBH EXAM }{FLD:TEXT 45}
Specimen to Lab: {FLD:RBH TO LAB}
NEURO:
AVPU level of consciousness:
(If score below A-Alert, complete GCS)
{FLD:RBH AVPU}
Pupils: {FLD:RBH ED PUPIL}
Glasgow:
Page 29 ED_NURSE_ENCOUNTERGlasgow Coma Scale:
Eye opening reponse: {FLD:NURS NEURO AROUSAL11}
Best verbal response: {FLD:F NUR NEURO VERBAL1}
Best motor response: {FLD:F NUR NEURO MOTOR1}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES}
Score: 15-13 Minor Brain Injury
9-12 Moderate Brain Injury
<8 Severe Brain Injury
Pupils: {FLD:RBH ED PUPIL}
Peds 2-5 y/o Glasgow Coma Scale
Eyes Open: {FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE EYE OPENING EYE OPEN}
Verbal:{FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE VERBAL RESPONSE }
Motor:{FLD:PR ER PEDS 2-5 Y/O GLASCOW COMA SCALE MOTOR RESPONSE}
{FLD:PR ER PEDS GLASGOW COMA READ SCALE}
Total Score: {FLD:GEN TEXT 5 SPACES1}
{FLD:WORD PROCESSING BOX1}
Infant Glascow Coma Scale:
Eye opening reponse: {FLD:NURS GCS INFANT AROUSAL}
Best verbal response: {FLD:NURS GCS INFANT VERBAL}
Best motor response: {FLD:NURS GCS INFANT MOTOR}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES}
Score: 15-13 Minor Brain Injury
9-12 Moderate Brain Injury
<8 Severe Brain Injury
Pupils: {FLD:RBH ED PUPIL}
======
Provider Notified at:{FLD:DATE & TIME(R)}
======
ASSESSMENT - PRIMARY
======
AIRWAY:
Patent, unobstructed airway
Abnormal airway
Airway obstructed - {FLD:WBH ER 1}
Trachea: {FLD:IHS ER TRACHEA}
Neck Veins: {FLD:IHS ER NECK VEINS}
Edema of Neck: {FLD:GEN YES/NO RADIO NO}{FLD:TEXT (1-40 CHAR)}
BREATHING:
Normal, non-labored, clear bilaterally. {FLD:TEXT (1-40 CHAR)}
Abnormal breathing:
Effort: {FLD:RBH EFFORT}
Sounds: {FLD:RBH SOUNDS} {FLD:TEXT (1-40 CHAR)}
CARDIOVASCULAR:
Heart rhythm/sounds: {FLD:NURS PULSE12}
Skin integrity: {FLD:RBH SKIN INTEGRITY}
Skin temperature: {FLD:RBH NUR TEMP}
Skin moisture: {FLD:RBH NUR MOIST1}
Skin color: {FLD:RBH NUR COLOR1}
Capillary refill: {FLD:NURS CARDIO CAP REFILL3}
Nail bed color: {FLD:F NUR COLOR1}{FLD:GEN TEXT BOX 15}
Edema: {FLD:RBH NUR EDEMA} {FLD:TEXT (1-40 CHAR)}
DISABILITY:
Glasgow Coma Scale:
Eye opening reponse: {FLD:NURS NEURO AROUSAL11}
Best verbal response: {FLD:F NUR NEURO VERBAL1}
Best motor response: {FLD:F NUR NEURO MOTOR1}
TOTAL POINTS: {FLD:GEN TEXT 5 SPACES12}
Pupils: {FLD:RBH ED PUPIL}
AVPU level of consciousness:
{FLD:RBH AVPU}
Pupils: {FLD:RBH ED PUPIL}
====== Page 34 ED_NURSE_ENCOUNTER
ASSESSMENT - SECONDARY FOCUSED
======
GENITOURNIARY:
Symptoms: {FLD:CIH ROS URINARY2} {FLD:TEXT (1-40 CHAR)}
GASTROINTESTINAL:
{FLD:IHS ER ABDOMEN1}
Bowel Sounds: {FLD:IHS ER BOWEL SOUNDS} {FLD:RBH BOWEL SOUNDS2}
Last Bowel Movement:{FLD:DATE ONLY} {FLD:TEXT (1-40 CHAR)}
REPRODUCTIVE:
Gender: Female
LMP: {FLD:GEN DATE1}{FLD:N/A1}
Pregnant?: No
Pregnant?: Yes
Estimated due date: {FLD:GEN DATE1}
Gender: Male
Denies any reproductive/sexual health issues
C/O of reproductive/sexual health issues: {FLD:TEXT (1-40 CHAR)}
EXTREMITIES:
Uniform in appearance, equal grip and strength, full ROM bilaterally, no
injuries.
Abnormal Findings: {FLD:RBH EXTREMETIES}{FLD:WORD 1 LINE}
======
INTERVENTIONS/PROCEDURES
======
IV ACCESS:
IV CARE:
{FLD:RBH IV CARE}
{FLD:EDIT 40/240}
IV Insertion:
Date/Time of insertion: {FLD:DATE & TIME2}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE21}{FLD:GEN TEXT BOX}
Type: {FLD:NURS IV TYPE13}
Size: {FLD:NUR ANGIOCATH SIZES21}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
Date/Time of insertion: {FLD:DATE & TIME2}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE21}{FLD:GEN TEXT BOX}
Type: {FLD:NURS IV TYPE13}
Size: {FLD:NUR ANGIOCATH SIZES21}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
{FLD:IHS CLICK HERE}{FLD:WORD PROCESSING 50/2}
IV Discontinuation:
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE112}{FLD:GEN TEXT BOX}
Date/Time discontinued: {FLD:DATE & TIME2}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
Location: {FLD:583 GEN LEFT/RIGHT1} {FLD:IV SITES UE112}{FLD:GEN TEXT BOX}
Date/Time discontinued: {FLD:DATE & TIME2}
{FLD:GEN OTHER}{FLD:GEN TEXT BOX LONG41}
CARDIAC MONITORING:
Date/Time of monitoring: {FLD:DATE & TIME2}
EKG:
Date/Time completed: {FLD:DATE & TIME2}
Type: 12 lead
OXYGENATION:
Oxygen Initiated:
Date/Time initiated: {FLD:DATE & TIME2}
O2 at {FLD:NUM 1-102}L/Min via {FLD:RBH O2 TYPE}
Oxygen Discontinued:
Date/Time discontinued: {FLD:DATE & TIME2}
CATHETERIZATION
Inserted foley: {FLD:DATE/TIME}
Size: {FLD:GEN TEXT 5 SPACES11} F Return: {FLD:GEN TEXT BOX 10 SPACES}
mLs water in balloon: {FLD:GEN TEXT BOX 10 SPACES}
Secured: {FLD:YES / NO} to {FLD:TEXT (1-40 CHAR)}
Description: {FLD:GEN WORD PROCESSING}
In/Out straight catheter done.
Time done: {FLD:DATE/TIME}
Reason: {FLD:GEN TEXT BOX LONG41}
Volume Out: {FLD:GEN TEXT 5 SPACES11} mls
{FLD:GEN OTHER}{FLD:GEN WORD PROCESSING}
Patient tolerated procedure: {FLD:PT TOLERATED}{FLD:WORD PROCESSING - 2 LINES}
WOUND CARE/ASSESSMENT:
Date of injury: {FLD:DATE ONLY}
Location: {FLD:RIGHT/LEFT11} {FLD:TEXT-30}
Page 42 ED_NURSE_ENCOUNTERShape: {FLD:WBH WOUND SHAPE}
Size: {FLD:GEN TEXT 5 SPACES12} {FLD:WBH CM MM} by {FLD:GEN TEXT 5 SPACES12}{FLD:WBH CM MM}
Dressing: {FLD:EDIT 40/240}
NIH STROKE SCALE:
Consciousness:{FLD:RCH NIHSS 1 CONSCIOUSNESS}
Month and age:{FLD:RCH NIHSS 2 MONTH AND AGE}
Opens and closes eyes:{FLD:RCH NIHSS 3 OPENS AND CLOSES EYES ON COMMAND}
Gaze:{FLD:RCH NIHSS 4 GAZE}
Visual field test:{FLD:RCH NIHSS 5 VISUAL FIELD TESTING}
Facial paresis:{FLD:RCH NIHSS 6 FACIAL PARESIS}
Motor function of right arm:{FLD:RCH NIHSS 7 MOTOR FUNCTION OF RIGHT ARM}
Motor function of left arm:{FLD:RCH NIHSS 8 MOTOR FUNCTION OF LEFT ARM}
Motor function of right leg:{FLD:RCH NIHSS 9 MOTOR FUNCTION OF RIGHT LEG}
Motor function of left leg:{FLD:RCH NIHSS 10 MOTOR FUNCTION OF LEFT LEG}
Limb ataxia:{FLD:RCH NIHSS 11 LIMB ATAXIA}
Sensory by pinprick:{FLD:RCH NIHSS 12 SESNORY BY PINPRICK}
Language:{FLD:RCH NIHSS 13 LANGUAGE}
Dysarthria:{FLD:RCH NIHSS 14 DYSARTHRIA}
Extinction and Inattention:{FLD:RCH NIHSS 15 EXTICTION AND INATTENTION}
STROKE SCALE SEVERITY:{FLD:RCH NIHSS 16 STROKE SCALE SEVERTIY}
Total Score: {FLD:GEN TEXT 5 SPACES11}***REQUIRED***
{FLD:WORD PROCESSING BOX1}
TEST/EXAMS/TREATMENTS:
Pt to Radiology for: {FLD:RBH EXAM }{FLD:TEXT 45}
Specimen to Lab: {FLD:RBH TO LAB}
GPA-N-ED-10 (Implemented 08-15-
2016)(Updated 12-1-2016 by CCC until 3-1-
17)(Revised 3-23-17 by CCC)
le-012502-Nursing Assessment
Used in
Multiple ED templates
Patient
Parent/Guardian
Spouse
Family Member
Friend
Transport Personnel
Medical Escort
Guard/Police Escort
Name
Date of birth
Chart number
Other -
Numeric Pain Rating Scale 1-10
Wong-Baker FACES Pain Rating Scale
FLACC Pain Scale
Minutes
Hours
Days
Weeks
Months
Years
Aching
Burning
Cramping
Pressure
Sharp
Stabbing
Numbness
Page 47 ED_NURSE_ENCOUNTERThrobbing
Tingling
Other:
Constant
Intermittent
Interrupts sleep
Activity induced
Yes
No
0 (No)
25 (Yes)
0 (No)
15 (Yes)
0 (None/bedrest/nurse assist)
15 (Crutches/cane/walker)
30 (Furniture)
0 (No)
20 (Yes)
0 (Normal/bedrest/wheelchair)
10 (Weak: short steps,stoops,light touch)
20 (Impaired: unsteady)
0 (Oriented to own ability)
15 (Overestimates/forgets limitations)
No Risk (0-24)
Low Risk (25-50)
High Risk (> 51)
Rails Up
Gown On
Family at Bedside
Sitting in Chair
A - Alert (Alert, oriented x3, able to obtain subjective information)
V - Verbal (Responds to verbal stimuli-opens eyes, not fully oriented)
P - Painful (Responds to painful stimuli only)
U - Unresponsive (Nonverbal and does not respond to painful stimulus)
PERRL
Brisk
Sluggish
Fixed
Dilated
Page 51 ED_NURSE_ENCOUNTER4 - Eyes open spontaneously
3 - Eyes open in response to sound
2 - Eyes open in response to pressure
1 - No eye opening response
NT - Non testable
5 - Oriented, e.g. to time, place,
person.
4 - Confused, speaks but is
disoriented.
3 - Intelligible single words
2 - Only moans/groans, sounds
1 - No audible response
NT - Non testable, factor interfering
with communication
6 - Obeys 2-part request, commands
Page 52 ED_NURSE_ENCOUNTER5 - Localizes painful stimulus
4 - Normal flexion, no predominant
abnormality
3 - Abnormal flexion, clearly
predominantly abnormal
2 - Extension, abnormal decerebrate
posturing
1 - No movement or posturing
NT - Non testable, paralysed or other
limiting factor
Spontaneous (4 points)
To verbal command (3 points)
To pain (2 points)
Absent (1 point)
Appropriate words/phrases (5 points)
Inappropriate words (4 points)
Persistant crying to pain(3 Points)
Page 53 ED_NURSE_ENCOUNTERGrunts/Moans to Pain (2 points)
Absent (1 point)
Obeys commands(6 points)
Localizes Pain(5 points)
Withdraws to Pain(4 points)
Abnormal Flexion to pain(3 points)
Abnormal Extension to pain(2 points)
Absent(1 point)
Score (Interpretation)
< 8 (Severe Head Injury and Coma)
9-12 (Moderate Brain Injury)
13-15 (Mild Brain Injury)
4 - Eyes open spontaneously
3 - Eyes open in response to voice
2 - Eyes open in response to pain
1 - No eye opening response
5 - Coos, babbles
4 - Irritable cry, consolable
3 - Cries persistently, inconsolable
2 - Moans/Grunts
1 - No response
6 - Normal, spontaneous movement
5 - Withdraws to touch
4 - Withdraws to pain
3 - Decorticate flexion
2 - Decerebrate extention
1 - No response
Object/debris
Loose teeth
Injury
Fluid
Singed nasal hair
Blood/debris in sputum
Stridor
Midline
Deviated Left
Deviated Right
Flat
Distended
No
Yes
Labored
Non-labored
Retractions
Nasal flaring
Stridor
Grunting
Clear
Abnormal -
Regular
Irregular
Pacemaker
Normal
Pale
Cyanotic
Mottled
Jaundiced
Flushed
[<3] secs
[>3] secs
pink
pale
dusky/cyanotic
Absent
Present -
None
Dysuria
Hematuria
Frequency
Urgency
Difficulty starting/stopping stream
Incontinence
Pruritus
Vaginal bleeding
Vaginal discharge
N/A
Soft
Non-tender
Tender
Page 60 ED_NURSE_ENCOUNTERFlat
Distended
Rigid
Nausea
Vomiting
Diarrhea
Present
Absent
Hypoactive
Hyperactive
x4 quadrants
RUQ
RLQ
LUQ
LLQ
Edited indent from 15 to 0, for use in template.
BCA -5/3/01
Injury
Weakness
Decreased movement
Decreased strength
Limited ROM
Amputation
No rashes
No induration
No nodules
Warm/Dry
Well Perfused
Significant findings:
Right
Left
round
oval
trapezoid
irregular
linear
cm
mm
STAGE 1, SUPERFICIAL
STAGE 2, EPIDERMIS
STAGE 3, DERMIS
STAGE 4, MUSCLE/SUB CUT FASCIA
STAGE 5, BONE
healthy
much granulation
moderate granulation
minimum granulation
necrotic
fibrinous exudate
bleeding
None
Scant
Moderate
Copious
Simple
Intermediate
Complicated
Suture
Staples
Derma Bond
Steri
le-012502-Nursing Assessment
Post Fall
0 Nausea and Vomiting
1 Mild Nausea with no Vomiting
2
3
4 Intermittent Nausea with Dry Heaves
5
6
7 Constant nausea,frequent dry Heaves
and vomiting
Document Observation 2,3,5,6
0 Not Present
1 Very mild harshness or or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
0 Not Present
1 Very Mild
2 Mild
3 Moderate
4 Moderately Severe
5 Severe
Page 68 ED_NURSE_ENCOUNTER6 Very Severe
7 Extremely Severe
0 None
1 Very mild itching,pins and needles, burning or numbness
2 Mild itching,pins and needles,burning or numbness
3 Moderate itching,pins and needles,burning or numbness
4 Moderate severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
0 No sweat visible
1 Barley perceptible sweating, palms moist
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats
Document Observation if level 2,3,5,6
0 Normal Activity
1 Somewhat more than normal activity
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the interview, or constantly thrashes about
Document observation if 2,3,5,6
0 None
1 Not visible, but can be felt fingertip to fingertip
2
3
4 Moderate, with patient's arms extended
5
6
7 Severe, even with arms not extended
Document Observation if level 2,3,5,6
0 Not Present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderate severe hallucinations
4 Extremely severe hallucinations
5 Continuous hallucinations
0 Oriented and can do serial additions
1 Cannot do serial additions or is uncertain about date
2 Disoriented with date by no more than two calendar day
3 Disoriented with date by more than two calendar day
4 Disoriented with place or person
0 No anxiety, at ease
1 Mildy anxious
2
3
4 Moderately anxious, or guarded, so anxiety inferred
5
6
7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
Blood Drawn
Flushes Easily
Page 71 ED_NURSE_ENCOUNTERNo Indications of infection
Dressing Clean, Dry and Intact
Other:
left
right
Antecubital
Hand
Forearm
Wrist
Foot
Upper Arm
Scalps
Peripheral Line
Saline Lock
CL Hickman
CL PICC
CL Subclavian
CL Jugular
CL Femoral
CL Port-A-Cath
CL Midline
CL Quintin
Other {FLD:GEN TEXT BOX}
18 gauge
20 gauge
22 gauge
24 gauge
25 gauge
Other/Comments:
(CLICK HERE TO ADD FREE TEXT INFORMATION)
antecubital
hand
forearm
Chest
1
2
3
4
5
6
7
8
9
10
nasal cannula
simple face mask
blow by
non-rebreather
parital rebreather
ventimask
Page 75 ED_NURSE_ENCOUNTERle-Resident's Note-
021102
Yes
No
Yes
No-explain
HLB 9/26/01
Sutures
I&D
Intubation
Pelvic Exam
Other:
CT
Ultrasound
X-Ray
Other:
Urine
Blood
Other:
GPA-N-ED-4 (Implemented 08-15-
2016)(Revised 3-23-17 by CCC)
Peripheral Line
Saline Lock
CL Hickman
CL PICC
CL Subclavian
CL Jugular
CL Femoral
CL Port-A-Cath
CL Midline
CL Quintin
Other {FLD:GEN TEXT BOX}
antecubital
hand
Page 79 ED_NURSE_ENCOUNTERforearm
Chest
1
2
3
4
5
6
7
8
9
10
Right
Left
Intact
Not intact
Warm
Hot
Cool
Cold
Normal
Dry
Moist
Diaphoretic
Peripheral Line
Saline Lock
CL Hickman
CL PICC
CL Subclavian
CL Jugular
CL Femoral
CL Port-A-Cath
CL Midline
CL Quintin
Other {FLD:GEN TEXT BOX}
1
2
3
4
5
6
7
8
9
10
0 - Alert
1 - Not alert, but arousable with minimal stimulation
2 - Not alert, requires repeated stimulation to attend
3 - Coma
0 - Answers both correctly
1 - Answers one correctly
2 - Both incorrect
0 - Obeys correctly
1 - Obeys one correctly
2 - Both incorrect
0 - Normal
1 - Partial gaze palsy
2 - Forced deviation
0 - No visual field loss
1 - Partial hemianopia
2 - Complete hemianopia
3 - Bilateral hemianopia
0 - Normal symmetrical movement
1 - Minor paralysis
2 - Partial paralysis (total or near total of lower face)
3 - Complete paralysis of one or both sides
0 - Normal
1 - Drift
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Untestable*
0 - Normal
1 - Drift
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Untestable*
0 - Normal
1 - Drift
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
0 - Untestable*
0 - Normal
1 - Drift
2 - Some effort against gravity
3 - No effort against gravity
4 - No movement
Page 85 ED_NURSE_ENCOUNTER0 - Untestable*
0 - None
1 - One limb
2 - Two limbs
0 - Normal
1 - Mild to moderate decrease in sensation
2 - Severe to total sensory loss
0 - No aphasia
1 - Mild-Moderate aphasia
2 - Severe aphasia
3 - No speech production
0 - None
1 - Mild-Moderate slurring
2 - Severe
0 - Intubated or other physical impediment to testing
0 - Normal
1 - Inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities
2 - Severe hemi-inattention or hemi-inattention to more than one modality
0 No stroke symptoms
1-4 Minor stroke
5-15 Moderate stroke
16-20 Moderate to severe stroke
21-42 Severe stroke
Page 87