MOUNT SINAI HOSPITAL Emergency Nursing Affix Patient Label

Joseph and Wall Lebovic Health Complex Care Record

Emergency Depertement
600 University Avenue
Toronto, Ostario, Canada M5G TKS
Form MS 560 TRIAL (Rev 10.2010)

Page 1 of 4
Date Time
YYYY MM DD HH . MM

Room

Presenting Health Problem Health History/Allergies

Smoker Yes No

Brought in by police: Badge # Security arrived to bedside: Time

HH . MM

 Airway  Pain
Patent Compromised Location________ Radiation__________
Quality_________ Time of onset _______
HH . MM

 Breathing Provoked by/Alleviated by_____________

No respiratory distress Mild distress Pain Score__________ /10
Moderate distress Severe distress
 Symptoms
Nausea______ Vorniting_________________
 Breath Sounds Diarrhea ____ Last bowel movernt__________
Equal, clear bilaterally Crackles Wheezes YYYY MM DD HHMM

Other  Sosial Situation Language Spoken_______

International Services contacted
 Circulation Lives with family/friend Lives alone
Skin colour_____ Skin temperature_____ Has CCAC
Other____________________________
Diaphoresis______
Clothing/Belongings/Own Medications given
to:
 Radial Pulse With patient Family Security
Strong Reguler Weak Irregular Other_____________
 Hydration
Well hydrated Mild dehydration
Moderate dehydration Severe dehydration
 Neurologic Awake, alert and oriented
Altered LOC (See Neuro Vital
Sign Record, page 3)
 ISAR (For all Patients >65) N/A
1) Before the illness or injury that
brought you to the Emergency, Yes 01
did you need someone to help No 00
you on a regular basis?
2) In the last 24 hours, have you Yes 01
needed more help than usual? No 00

 Abdomen N/A 3) Have you been hospitalized for Yes 01

one or more nights during the No 00
Bowel Sounds______ Distention___________
past six months?
Guarding__________ Rigidity_____________
4) In general, do you have problems Yes 01
 Genitc-Urinary N/A with your vision? No 00
Dysuria__________ Hematuria_______________
Frequency________ Flank pain Right Left 5) In general, do you have serious Yes 01
problems with your memory? No 00
 Gynecologic N/A
Last menstrual period_______ Gravida/para______ 6) Do you take six or more Yes 01
YYYY MM DD
medications every day? No 00
Vaginal bleeding Amount_____ Duration________ Total /6
Positive test is 2 or more