NAME A&E NUMBER

DATE / / / ARRIVAL
AARRIVAL
hrs TIME OF INJURY hrs
NURSING ASSESSMENT
ACCIDENT AND EMERGENCY DEPARTMENT
AMBULANCE REPORT
CARDIAC TAMPONADE
PRE HOSPITAL CARE
MEDICATION
AMOUNT ROUTE
TIME ON SCENE hrs
hrs
ON SCENE: RESPS PULSE
BP GCS
O2 VIA MASK OROPHARYNGEAL AIRWAY NASOPHARYNGEAL AIRWAY
ET TUBE
IV CANNULA
IV FLUIDS Mls
C!SPINE IMMOBILISATION
SPINAL BOARD
TIME
TIME LEFT SCENE
PRIMARY SURVEY
AIRWAY
ASSESSMENT RESUSCITATION
CLEAR GAG YN O2 VIA MASK "
OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
ET TUBE SI#E
C!SPINE
COMPROMISED
CLEAR SUSPECT COLLARBAGS IN!LINE IMMOBILISATION
BREATHING
SPONTANEOUS
RESP RATE
S$O2 "
NORMAL BREATH SOUNDS
FLAIL SEGMENT
TENSION PNEUMOTHORA%
PNEUMOTHORA% OPENCLOSED
HAEMOTHORA%
L R
L R
L R
L R
VENTILATED Y N
NEEDLE THORACOCENTESIS
L R
CHEST DRAIN SITE
SI#E
CARDIAC TAMPONADE
Georgia Francesca
637254
4
5
Asthma in a 5-year old
0201
2011
2
28 105
112/ 65 2+2+5!
12"25
#
#
0"25
#
!1
#
#
#
28
!1
UNITS
UNITS
CIRCULATION
SYSTOLIC BP ON ARRIVAL
HAEMORRHAGE
E%TERNAL SITE
CHEST
ABDO
PELVIS
IV CANNULA SI#E SITE
SI#E SITE
INTRAOSSEOUS LINE SITE
BLOOD ORDERED TIME
O NEG
hrs
UNITS
GROUP SPECIFIC UNITS
CROSS MATCH UNITS
GROUP & SAVE UNITS
DISABILITY
ALERT
EYES OPEN TO VERBAL STIMULUS
EYES OPEN TO PAINFUL STIMULUS
UNRESPONSIVE
NOTES
E%POSURE
FULLY UNDRESS PATIENT TEMP ORAL RECTAL A%ILLA
SECONDARY SURVEY
LACERATION +++
FRACTURE #
BRUISING //////
PAIN P
TENDERNESS T
PUNCTURE/STAB o
LOG ROLL
RECTAL E%AM
START FLUID VOL RATE DRs SIG NURSE SIG END TOTAL IN
SITE
IV ACCESS 2
SITE
START FLUID VOL RATE DRs SIG NURSE SIG END TOTAL IN
IV ACCESS &
SITE
START FLUID VOL RATE DRs SIG NURSE SIG END TOTAL IN
IV ACCESS '
113 22
$" $%ng
#
#
!8"7
0
P
T
%!RAYS BLOODS
BM STICK (()ls C!SPINE CHEST PELVIS SPINE USS CT SCAN RESULTS H* WCC PLATELETS N+ KUREA CREATININE BLOOD GLUC
URINE
CATHETER URETHRAL SUPRAPUBIC BLOOD KETONES GLUCOSE PROTEIN B!HCG ABG $O2 $CO2 $H BE CO TO%ICOLOGY ALCOHOL AMYLASE
PERITONEAL LAVAGE
((
&
MICRO RBC ((
&
Y N
BACTERIA FOOD PERFORMED BY: TIME
hrs
WBC
DRUGS
NAME DOSE ROUTE DRs SIG GIVEN BY TIME
TETANUS TOXOID 0.5ml SC / IM
HUMOTET 250i IM
ALLERGIES
FLUID OUTPUT
CATHETER:
URETHRAL
SUPRAPUBIC
TIME VOLUME TOTAL
OTHER LOSSES
TIME VOLUME TOTAL
A&E FLUID BALANCE
TOTAL CRYST
TOTAL COLL
TOTAL BLOOD
OTHER
TOTAL IN
IN OUT
URINE
EST FOR ,s
CHEST DRAINS
OTHER
TOTAL OUT
PERSONNEL
ACCIDENT & EMERGENCY
GRADE CALLED ARRIVED NAME
TRAUMA ORTHOPAEDIC
ANAESTHETIST
GENERAL SURGEON
NURSE '
NURSE 2
NURSE &
OBSERVERS
MINS
HRS
!50 !"0
OBSERVATIONS
#$o%&'%(o#l) *
TIME
&o #$((+, -
TIME
&o $'i% 2
TIME
No%( !
TIME
o.i(%&'&(/ 5
TIME
+o%0#(/ *
TIME
i%'$$.o$.i'&( - i%+om$.(,(%#i1l( 2
TIME
%o%( !
TIME
o1()# +omm'%/# " lo+'li#(# $'i% 5 %o.m'l 0l(2io% * '1%o.m'l 0l(2io% - (2&(%#io% &o $'i% 2 %o%( ! TOTAL GCS
G
L
A
S
G
O
W

C
O
M
A

S
C
O
R
E
P
U
P
I
L
S
L
I
M
B
S
RIGHT LEFT ARMS LEGS '#)mm(&.i+'l '#)mm(&.i+'l #)mm(&.i+'l #)mm(&.i+'l .('+&io% .('+&io% #i3( 4mm5 #i3( 4mm5 S$O
2
RESP RATE20 -0 *0 50 "0 60 70 80 !00 !!0 !20 !-0 !*0 !60
!70
!80
200
2!0
220
CVP H2-
PUPILS
+
REACTS
9
NO REACTION
C SL
CLOSED SLUGGISH

OTHER INFORMATION
NE%T OF KIN RELATIONSHIP
' 2
FAMILY SPOKEN TO: YN
DOCTOR NURSE PROPERTY IN SAFE RECEIPT NO HANDED OVER HANDED TO POLICE CONTACT NAME BADGE NO STATION

NOTES DISPOSAL
CT THEATRE ITU WARD TRANSFER WARD HOSP OTHER TIME LEFT