DATE:
PATIENT IDENTIFICATION
ED TRAUMA FLOW SHEET
NOTIFICATION STATUS
TIME OF NOTIFICATION
MECHANISM OF INJURY
ROOM #
TIME
ARRIVED
DATE
INJURY
ASSAULT
CODE YELLOW PAGED
COMMENTS: ___________________________________________________________
BURN
FRONT
BACK
OTHER:
___________________________
CRUSH
COMMENTS: ___________________________________________________________
POLICE
DROWN
COMMENTS: ___________________________________________________________
AMBULANCE
WALK IN
FALL
DISTANCE: ____________________________________________________________
AUTO
OTHER
GSW
LOCATION: ____________________________________________________________
YES
NO
MODE OF ARRIVAL
MVC
PRE - HOSPITAL CARE
OXYGEN THERAPY
VIA
NONE
AIRWAY
ACLS
NONE
EOA
ETT
ECG
ORAL
BACKBOARD
LONG
SHORT
SCOOP
OTHER
MEDS
IV'S
OTHER
NONE
TRAUMA TEAM RESPONSE
DEFIB
CERVICAL COLLAR (TYPES)
NONE
DRESSINGS
MOTORCYCLE
RESTRAINED
UNRESTRAINED
HELMET
STEERING WHL
AIRBAG
EXTRICATED
EJECTED
DRIVER
PEDESTRIAN
PASSENGER
STABBING
LITERS
AT
BICYCLE
NO HELMET
LOCATION: ____________________________________________________________
DEATH ON SCENE
COMMENTS: _______________________________________________
ESTIMATED TIME OF INJURY
DESCRIBED DETAILS
NONE
SPLINTS
NONE
NAME
ARRIVED TIME/CALLED IN
ED PHYSICIAN
PRIEST
AGE
SURGEON
SEX
DOB
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
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
PAGE 1 of 6
PUPIL LEGEND
2
3
4
5
6
7
8
9
1:
TIME
D=Dilated
E=Equal
2:
3:
F=Fixed
P=Pinpoint
4:
5:
BP
PULSE:
ARTERIAL BLOOD GASSES
TIME
F l O2
Ph
p CO 2
pO
H C O3
2
RESP RATE
TEMP
O 2 SAT
GCS
/
PUPILS L / R
6:
TIME
/
7:
/
8:
/
9:
/
10:
BP
PULSE:
RESP RATE
TEMP
MEDICATIONS
TIME
DRUG
DOSE
O 2 SAT
ROUTE
SITE
INITIALS
GCS
/
PUPILS L / R
11:
TIME
/
12:
/
13:
/
14:
/
15:
BP
PULSE:
RESP RATE
TEMP
O 2 SAT
GCS
/
PUPILS L / R
16:
TIME
UNIT #
PRBC WB
SITE
BY
/
20:
RESP RATE
TIME:
TIME
UP
/
19:
PULSE:
TIME SPECIMEN SENT:
EMERGENCY 2 Units of PRBC:
/
18:
BP
BLOOD PRODUCTS
TYPE & CROSS:
/
17:
TEMP
TIME
DOWN
TOTAL
O 2 SAT
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
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
PAGE 2 of 6
INITIAL ASSESSMENT
A
AIRWAY
AIRWAY PATENT:
ARTIFICIAL AIRWAY:
TIME PLACED:
YES
NA
CERVICAL COLLAR:
TIME PLACED
TIME REMOVED
BACKBOARD:
TIME PLACED
TIME REMOVED
NO
ORAL
PTA
NONE
PTA
NONE
PTA
BREATHING
L
BREATH SOUNDS:
DIMINISHED
ABSENT
RALES
WHEEZE
PULSE OX
O 2 THERAPY
TIME STARTED
NC
@
NRBM
@
BVM
@
ETT
CIRCULATION
N0
SHALLOW
PARADOXICAL
R
L/M
L/M
L/M
VENTILATION
TV
RATE
F10 2
PEEP/CPAP
BY
TAPED AT
PULSES
PALE
COOL
> 2 SEC
MUFFLED
PRESENT
BY
DUSTY
DRY
< 2 SEC
CLEAR
ABSENT
SKIN COLOR:
PINK
SKIN:
WARM
ABSENT
CAP REFILL:
APICAL HEART TONES:
JVD:
CPR:
TIME STARTED
D
NEUROLOGICAL
EFFECTS
ALERT
VERBAL
PAIN
3
4
5
6
LOC - ORIENTED X3:
PERSON
TIME
PLACE
ALERT
ORIENTED X3
SOMNOLENT
UNCONSCIOUS
VERBAL
EVENT RECALL
CONFUSED
TRANSIENT LOSS OF
CONSCIOUSNESS
7
8
EYES
OPEN
BEST
VERBAL
RESPONSE
BEST
EXTREMITY MOVEMENT:
R ARM
DEFORMITY
R LEG
DEFORMITY
L ARM
DEFORMITY
L ARM
DEFORMITY
YES
YES
YES
YES
YES
YES
YES
YES
RESPONSE
NO
NO
NO
NO
NO
NO
NO
NO
Spontaneously
To Speech
To Pain
None
Oriented
Confused
Inappropriate Sounds
Incomprehensible
None
Obeys Command
Localizes Pain
Withdraws to Pain
Flexes to Pain
Extends to Pain
None
GLASCOW COMA
TOTAL
Paralytic Agents
On Board?
Suspected
Substance Abuse?
L
FEMORAL
POPLITEAL
DORSALIS
PEDIS
S=Strong
D=Doppler
R
BRISK
SLUGGISH
NO RESPONSE
SIZE
GLASCOW COMA SCALE INITIAL
MOTOR
UNCONSCIOUS
9
R
CYANOTIC CARTOID
MOIST
BRACHIAL
PALLOR RADIAL
PUPILS:
2
NO
ETT
TYPE
BY
BY
TYPE
BY
BY
TIME INTUBATED
SIZE TUBE
C
YES
TRACH
YES
NORMAL
RETRACTIONS
SPONTANEOUS RESP. EFFORT:
CHEST MOVEMENT:
B
SPONT. RESP. EFFORT
NT
EOA
BY
4
3
2
1
5
4
3
2
1
5
5
4
3
2
1
W=Weak
A=Absent
L
REVISED COMA SCALE INITIAL
4
3
2
1
5
4
3
2
1
5
5
4
3
2
1
GLASCOW
COMA
-2
-3
4
4
3 or less
89 mm Hg
76 - 88 mm Hg
50 - 75 mm Hg
1 - 49 mm Hg
No Pulse
10 - 29 / Min
29 / Min
6 - 9 / Min
1 - 5 / Min
None
0
4
3
2
1
0
4
3
2
1
0
0
4
3
2
1
0
4
3
2
1
0
TOTAL
SYSTOLIC
BLOOD
PRESSURE
RESPIRATORY
RATE
Y/N Y/N
TOTAL
REVISED
TRAUMA
SCORE
Y/N Y/N
PART OF THE MEDICAL RECORD
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
PAGE 3 of 6
E
F
G
EXPOSE PATIENT
COMPLETELY
FAHRENHEIT
BLANKETS
GET FULL SET
(vs.) TIME
BP
R ARM
HEAD TO TOE
WARMING LIGHTS
BP
L ARM
HEART
RATE
ORAL/RECTAL TEMPERATURE
OPEN CARDIAC
MASSAGE
CODE BLUE
SHEETS
INTERNAL DEFIB
CRIC
MONITOR
PRINTOUT
OF BP+HR:
Separate SHEET
RATE
INITIAL OUTPUT
TIME BY
ELECTROCARDIOGRAM / 12 LEAD
PERITONEAL LAVAGE
CHEST TUBE #1
SITE:
SIZE:
CHEST TUBE #2
SITE:
SIZE:
FOLEY SIZE
NG TUBE SIZE
MONITOR STRIP
H
HEAD
TO TOE
BLEEDING
NEEDLE DECOMPRESSION
LARGE BORE IV
PERICARDIOCENTESIS
LARGE BORE IV
NORMAL / INTACT SKIN
A= ABRASION
L= LACERATION
B= BURN
M= AMPUTATING
C= CLOSED/SUSPECTED
O= OPEN FRACTURE
FRACTURE
P= PAIN
D= DEFORMITY
S= STABWOUND
E= ECCHYMOSIS
V= AVULSION
G= GUNSHOT WOUND
Z= OTHER: ___________________
ABDOMEN:
CSF EARS
CENTRAL LINE
GAUGE: __________________
VOMITING
NON-TENDER
STABL
PELVIS:
DISTENDED
TENDER
STOOL GUAIC:
UNSTABLE TO PALPITATION
NOSE
I
INSPECT BACK
FIRM
RECTAL TONE:
PAIN TO PALPITATION
SPONT. VOID
GENITOURINARY:
URINE:
BOWEL SOUNDS
SOFT
INCONTINENT
COLORLESS
YELLOW
RED
BROWN
UPT
CLOUDY
NONE
URINE DIP
VAGINAL BLEEDING:
NO
YES
PRIAPISM:
INSPECT THE BACK:
TIME
LOG ROLL:
INJURIES
NO
YES
PART OF THE MEDICAL RECORD
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
PAGE 4 of 6
INTAKE
IV# / AMT
SITE
SOLUTION
TIME UP
OUTPUT
BY
TIME DOWN
TIME / AMOUNT
TOTAL
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: ______________________
O2
RN
BELONGINGS: ________________________________________________________________________________________
TRANSFERRED:
TO:___________________________________
VIA: ______________________________________
BELONGINGS: ________________________________________________________________________________________
TIME LEFT ED: ___________________________________
DEATH:
TRANSFER FORM COMPLETED:______________
TIME OF DEATH:_________________________
TIME PMD NOTIFIED: _____________________
TIME CORONER NOTIFIED: ________________
DONOR FORM COMPLETED:
YES
PRONOUNCED BY: _________________________
CODE BLUE SHEET COMPLETED: ___________________________
SIGNED DEATH CERTIFICATE?
NO
TIME BODY MOVED: _____________________
POLICE/HOMICIDE:
WRTC NOTIFIED:
CORONER
TIME NOTIFIED: _____________________
YES
NO
YES
NO
MORGUE
TIME RESPONDED: ______________________
MD SIGNATURE: _________________________________
PRIMARY NURSE'S SIGNATURE /
DATE: ______________
TITLE: ___________________________________________________
PART OF THE MEDICAL RECORD
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
PAGE 5 of 6
NURSES NOTES
NAME:
DATE / TIME:
COMMENTS:
RN SIGNATURE / TITLE
RN SIGNATURE / TITLE
PRINT NAME
PRINT NAME
PART OF THE MEDICAL RECORD
8850011 Rev 05/05
ED Trauma Flow Sheet_EMERGENCY ROOM
PAGE 6 of 6