Emergency Department - Trauma/Accident Patient Assessment Admission Form

Emergency Department - Trauma/Accident Patient Assessment Form

Hospital Name: ________________________________________

General Information

• Patient Name: ________________________________________

• HN: _______________________ VN: ______________________

• Date: _______________________ Time: ___________________

• Age: _______ years  Gender: ( ) Male ( ) Female

• Mode of Arrival: ( ) ALS ( ) BLS ( ) Walk-in ( ) Other: ______________

• Referred From: ________________________________________

• Mechanism of Injury (if known): _____________________________________

• Protective Devices Used (e.g., seatbelt, helmet): ______________________

• Allergies: ________________________________________________________

• Past Medical History: _______________________________________________

Initial Nurse/Triage Assessment

• Triage Nurse: ________________________________________

• Triage Level: ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5

• Vital Signs:

  
  

   BP: __________ mmHg (Arm: Rt / Lt)

  
  

   HR (PR): ______ bpm

  
  

   RR: ______ breaths/min

  
  

   Temp: ______ °C

  
  

   SpO₂: ______ % (on: Room Air / O₂ at ____ LPM)

• Pain Score (0-10): ______

• Primary Complaint: _____________________________________

Pre-Hospital Care Information

• Provided By: ( ) ALS ( ) BLS ( ) First Responder ( ) Other: ___________

• Interventions Done Pre-Hospital (e.g., IV fluids, C-spine immobilization):

Primary Assessment - ABCDE

A. Airway with C-Spine ProtectionAssessment:

• Airway Patency: ( ) Clear ( ) Partially Obstructed ( ) Obstructed

• Signs of Airway Compromise (stridor, gurgling, snoring): ______________

• C-Spine Injury Suspected: ( ) Yes ( ) No

  • If Yes: Reason (neck pain, tenderness, MOI): ______________________

Management:

• ( ) Suction

• ( ) Oral Airway (OPA) / Nasal Airway (NPA)

• ( ) Endotracheal Intubation ETT/NTT: Size: _______ Mark: ______ cm Time: ______

• ( ) Rigid Cervical Collar

• ( ) Spinal Board / Manual In-Line Stabilization

• Other: ____________________________________________________

B. Breathing and VentilationAssessment:

• Respiratory Status: ( ) Normal ( ) Dyspnea ( ) Apneic

• Tracheal Deviation: ( ) Midline ( ) Deviated Rt / Lt

• Chest Expansion: ( ) Equal ( ) Unequal

• Subcutaneous Emphysema: ( ) Rt ( ) Lt

• Breath Sounds: ( ) Normal ( ) Decreased/Absent Rt / Lt / Both

• Possible Pneumothorax: ( ) Rt ( ) Lt ( ) Both

• Possible Hemothorax: ( ) Rt ( ) Lt ( ) Both

Management:

• Oxygen Delivery: ( ) Mask at _____ LPM ( ) BVM at _____ LPM ( ) NRB at _____ LPM

• ( ) Needle Decompression: Rt / Lt / Both (Site: ______ )

• ( ) Chest Tube Insertion:

  
  

   Side: Rt / Lt

  
  

   Size: ______

  
  

   Mark: ______ cm at Skin

  
  

  Time: ______

• ( ) 3-Sided Sterile Occlusive Dressing (if open pneumothorax)

• ( ) Portable CXR / Ultrasound (e.g., eFAST)

• Other: ____________________________________________________

C. Circulation with Hemorrhage ControlAssessment:

• Pulse Quality: ( ) Full ( ) Weak ( ) Absent

• BP: ______ mmHg (Repeat: ______ mmHg Time: ______)

• Capillary Refill: ( ) <2 sec ( ) >2 sec

• Active External Bleeding: ( ) Yes ( ) No

• Pelvic Compression Test: ( ) Positive AP/Lateral ( ) Negative

• Skin Perfusion (color, temperature): ________________________________
  

Management:

• IV Access: ( ) Peripheral IV: #_____ G Rt / Lt ( ) IO Access

• IV Fluids: Type: __________ Rate: ______ mL/hr

• ( ) Direct Pressure to Bleeding Wound

• ( ) Suture / Wound Closure

• ( ) Tourniquet Placement: Limb: __________ Time: ______

• Blood Products: ( ) PRC ( ) FFP ( ) Platelets ( ) MTP Protocol Initiated

• Cardiac Monitoring ( ) Yes (Lead: ______ )

• Labs: ( ) CBC ( ) BUN/Cr ( ) Electrolytes ( ) LFT ( ) Coag Panel ( ) Crossmatch

• Other Interventions: ____________________________________________

D. Disability (Neurological Status)Assessment:

• GCS: E____ V____ M____ Total: ______

• Pupils:

  
  

   Rt: ______ mm Lt: ______ mm

  
  

   Reaction: ( ) Reactive ( ) Non-Reactive

• Lateralizing Signs / Weakness: ( ) Rt ( ) Lt

• Any Seizure Activity: ( ) Yes ( ) No

Management:

• Consider Advanced Airway if GCS ≤ 8

• ( ) Secure C-Spine Alignment

• ( ) Glucose Check (DTX): __________ mg/dL

• Other Interventions: ____________________________________________

E. Exposure/Environmental ControlAssessment:

• Fully Expose the Patient: ( ) Yes

• Log Roll: ( ) Normal Alignment ( ) Spinal Tenderness / Deformity

• PR (Rectal Exam): ( ) Normal Tone ( ) Reduced Tone

• Fresh Blood on Underclothes/Perineum: ( ) Yes ( ) No

• Bulbocavernosus Reflex: ( ) Positive ( ) Negative

• Perineum / External Genitalia: ( ) Normal ( ) Abnormal

Management:

• ( ) Keep Patient Warm (Blankets, Warm IV Fluids)

• ( ) NG/OG Tube Insertion: Time: ______

• ( ) Foley’s Catheter Placement: Time: ______

  
  

  Urine Color: __________ Volume: ______ mL

• Wound Care / Splinting of Fractures: _______________________________

• Other Interventions: ____________________________________________

Additional Assessments/Secondary Survey (As Time/Condition Permits)

• Head-to-Toe Examination Findings: _________________________________

• Additional Imaging: ( ) CT ( ) MRI ( ) FAST Exam ( ) Other: __________

• Additional Labs: _________________________________________________

• Tetanus Prophylaxis: ( ) Given ( ) Not Given

• Antibiotics: ( ) Given (Type: __________ ) ( ) Not Given

Prepared By: ________________________________________ (Name & Designation) Signatures/Approvals:

• Physician: ____________________________________ Date/Time: ____________

• Nurse: _______________________________________ Date/Time: ____________

• Other: _______________________________________ Date/Time: ____________

Comments/Notes: ___________________________________________________