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Emergency & Trauma Card

The document is an Emergency & Trauma Card used for recording patient history and physical examination details upon arrival at a medical facility. It includes sections for patient demographics, emergency severity index, vital signs, assessment using the Glasgow Coma Scale, and a plan of care. Additionally, it outlines necessary blood and body fluid investigations to be conducted.

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vikash
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135 views2 pages

Emergency & Trauma Card

The document is an Emergency & Trauma Card used for recording patient history and physical examination details upon arrival at a medical facility. It includes sections for patient demographics, emergency severity index, vital signs, assessment using the Glasgow Coma Scale, and a plan of care. Additionally, it outlines necessary blood and body fluid investigations to be conducted.

Uploaded by

vikash
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Emergency & Trauma Card

PATIENT HISTORY & PHYSICAL EXAMINATION SHEET

Name: Time of Arrival:

Age/Sex: Mode of Arrival:

Date & Time: Ambulance Self

Emergency Severity Index:


1 (exigent), 2 (emergent), 3 (urgent), 4 (less urgent), 5 (no urgent)

MLC: Yes
MLC No. Inside Outside

SIGNS / SYMPTOMS:

ALLERGY:
MEDICATIONS:

PAST ILLNESSES:

LAST MEAL:

LAST MENSTRUAL CYCLE:


EVENTS LEADING TO PRESENT CONDITION/INJURY:
VITALS & EXAMINATION: Chest:

Pulse: Temp: RR:_______

BP: SPO2 at room air:

SPO2 with 02: RBS:

Pain Score:

CVS:

0 1 2 3 4 5 6 7 8 9 10

Assessment:
GCS :
Glasgow Coma Scale
Response Scale Score
Eyes open spontaneously 4 Points Abdomen:
Eyes open to verbal command. speech, or shout 3 Pants
Eye Opening Response Eyes open to pain (not applied to face) 2 Points
No eye opening 1 Point

Oriented 5 Points
Confused Conversation, but able to answer Questions 4 Points
Inappropriate responses. words discernible 3 Points
Verbal Response
Incomprehensible sounds or speech 2 Points

No verbal response 1 Point


Obeys commands for movement 6 Pants
Purposeful movement to Painful stimulus 5 Points
Withdraws from pain 4 Points
Motor Response Abnormal (spastic, flexion), decorticate posture 3 Points
Extensor (rigid) response. decelerate posture 2 Points
No motor response 1 Pant Limb :
Minor Brain injury = 13-15 point; Moderate Brain injury = 9.12 points; Severe Brain injury = 3.8 points

Upper

Prognosis Explained :

Lower
Patient / Attendant Sign

Plan of Care:

Blood & Body fluid Investigations:

CBC TropT Blood Culture Amylase

KFT ABG Urine Culture S. Lipase

LFT SOB Panel Tracheal Culture Other

PT/INR Cardiac 2 Panel Urine R&M

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