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 SkinTime: ______
• ( ) 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: ___________________________________________________