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: ___________________________

YES NO CRUSH COMMENTS: ___________________________________________________________

MODE OF ARRIVAL POLICE DROWN COMMENTS: ___________________________________________________________

AMBULANCE WALK IN FALL DISTANCE: ____________________________________________________________

AUTO OTHER GSW LOCATION: ____________________________________________________________

MVC BICYCLE MOTORCYCLE RESTRAINED UNRESTRAINED

PRE - HOSPITAL CARE NO HELMET HELMET STEERING WHL AIRBAG EXTRICATED

OXYGEN THERAPY NONE EJECTED DRIVER PEDESTRIAN PASSENGER

VIA AT LITERS STABBING LOCATION: ____________________________________________________________

AIRWAY NONE ACLS DEFIB OTHER DEATH ON SCENE COMMENTS: _______________________________________________

EOA ETT ORAL ECG MEDS IV'S ESTIMATED TIME OF INJURY

BACKBOARD NONE CERVICAL COLLAR (TYPES) DESCRIBED DETAILS
LONG SHORT SCOOP OTHER NONE

DRESSINGS NONE SPLINTS 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

8850011 Rev 05/05 ED Trauma Flow Sheet_EMERGENCY ROOM PAGE 1 of 6
 PUPIL LEGEND D=Dilated E=Equal F=Fixed P=Pinpoint
2 3 4 5 6 7 8 9 TIME 1: 2: 3: 4: 5:

BP
PULSE:
RESP RATE
ARTERIAL BLOOD GASSES TEMP
TIME F l O2 Ph p CO 2 pO 2 H C O3 O 2 SAT
GCS
PUPILS L / R / / / / /
TIME 6: 7: 8: 9: 10:

BP
PULSE:
RESP RATE
TEMP
MEDICATIONS O 2 SAT
TIME DRUG DOSE ROUTE SITE INITIALS GCS
PUPILS L / R / / / / /
TIME 11: 12: 13: 14: 15:

BP
PULSE:
RESP RATE
TEMP
O 2 SAT
GCS
PUPILS L / R / / / / /
TIME 16: 17: 18: 19: 20:

BP
BLOOD PRODUCTS PULSE:
TYPE & CROSS: TIME SPECIMEN SENT: RESP RATE
EMERGENCY 2 Units of PRBC: TIME: TEMP
UNIT # PRBC WB SITE TIME BY TIME TOTAL O 2 SAT
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

8850011 Rev 05/05 ED Trauma Flow Sheet_EMERGENCY ROOM PAGE 2 of 6
 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 2 THERAPY TIME STARTED
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
BRISK R L

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 GLASCOW -2 4 4
LOGICAL PLACE EYES To Speech 3 3 COMA -3
EFFECTS ALERT OPEN To Pain 2 2 TOTAL
ORIENTED X3 None 1 1 3 or less 0 0
SOMNOLENT Oriented 5 5 89 mm Hg 4 4
UNCONSCIOUS BEST Confused 4 4 SYSTOLIC 76 - 88 mm Hg 3 3
ALERT VERBAL VERBAL Inappropriate Sounds 3 3 BLOOD 50 - 75 mm Hg 2 2
EVENT RECALL RESPONSE Incomprehensible 2 2 PRESSURE 1 - 49 mm Hg 1 1
VERBAL CONFUSED None 1 1 No Pulse 0 0
TRANSIENT LOSS OF Obeys Command 5 5 10 - 29 / Min 4 4
PAIN CONSCIOUSNESS BEST Localizes Pain 5 5 RESPIR- 29 / Min 3 3
MOTOR Withdraws to Pain 4 4 ATORY 6 - 9 / Min 2 2
UNCONSCIOUS EXTREMITY MOVEMENT: RESPONSE Flexes to Pain 3 3 RATE 1 - 5 / Min 1 1
R ARM YES NO Extends to Pain 2 2 None 0 0
DEFORMITY YES NO None 1 1
R LEG YES NO GLASCOW COMA TOTAL
DEFORMITY YES NO TOTAL REVISED
L ARM YES NO Paralytic Agents TRAUMA
Y/N Y/N
DEFORMITY YES NO On Board? SCORE
L ARM YES NO Suspected
Y/N Y/N
DEFORMITY YES NO Substance Abuse?

PART OF THE MEDICAL RECORD

8850011 Rev 05/05 ED Trauma Flow Sheet_EMERGENCY ROOM PAGE 3 of 6
 E
EXPOSE PATIENT COMPLETELY HEAD TO TOE

F
FAHRENHEIT BLANKETS WARMING LIGHTS

G
GET FULL SET
BP
R ARM
BP
L ARM
HEART
RATE RATE
MONITOR
PRINTOUT
OF BP+HR:
(vs.) TIME ORAL/RECTAL TEMPERATURE Separate SHEET

OPEN CARDIAC TIME BY INITIAL OUTPUT

MASSAGE ELECTROCARDIOGRAM / 12 LEAD
PERITONEAL LAVAGE
CODE BLUE CHEST TUBE #1
SHEETS SITE: SIZE:
CHEST TUBE #2
INTERNAL DEFIB SITE: SIZE:
FOLEY SIZE
CRIC NG TUBE SIZE

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 BACK
INSPECT THE BACK:

LOG ROLL:
TIME

INJURIES

PART OF THE MEDICAL RECORD

8850011 Rev 05/05 ED Trauma Flow Sheet_EMERGENCY ROOM PAGE 4 of 6
 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: ______________________ O2 RN
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 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