WHO EMERGENCY UNIT FORM: GENERAL □ Mass Casualty

Form to be used with WHO Reference Card. See who.int/emergencycare for more information.
Hospital Registration Number: Date: DD/MM/YY Time of Arrival: : _ _ (24h)
Patient Surname: Age: ________ Arrival Mode: □Ambulance □Car/Truck (circle Private or Taxi)
First Name: □ Motorized 2/3-wheeler (circle Private or Taxi)
INF / CH / AD □ Public Transport □ Walk □ Other: __________________
Gender: □Male □Female Date of Birth:
□ Other: ___________ DD/MM/YY Weight: kg Number of prior facilities: ____
Referred from:
Occupation: □ Unknown
Patient Residence (at least City and Sub-district):
□ Unknown □Ambulatory Non Ambulatory: □ Acute □ Chronic
Contact Person: Phone: Relation:

CHIEF COMPLAINT: Triage Category:

INITIAL VS at : _ _ (24h)
Temp:____ BP:____ / ____ Pulse:_____ RR:____
SpO2:____ % on ___________ Pain score: ____ / 10
TREATING PROVIDER ASSESSMENT: Date: DD/MM/YY Time : _ _ (24h) □ Dead on arrival
HIGH RISK SIGNS
□ Abnormal AVPU □ HR <55 or >130 (adult) □ Temp >39˚C or <36˚C □ SpO2 <90% on RA
□ Stridor, voice change or unable to swallow □ Respiratory distress (grunting in child, retractions, cyanosis)
□ Poor perfusion, weak pulse, capillary refill >3s □ Vomits everything, can’t drink or feed

PRIMARY SURVEY: (see Reference Card for normal findings, only mark NML if all key elements are normal)
□ Angioedema □ Stridor □ Voice changes Airway: □ Repositioning □ Suction □ OPA □ NPA □ LMA
Airway □ Oral/Airway burns
Obstructed by: □ Tongue □ Blood □ Secretions
□ BVM □ ETT
□ NML □ Vomit □ Foreign body
Spontaneous Respiratory Rate: _____________ Oxygen: _____ L Chest needle or tube (circle):
Chest Rise: □ Shallow □ Retractions □ Paradoxical □NC □Mask □NRB □ L – Size: _____ Depth: ______ cm
B reathing Trachea: □ Midline □Deviated to □L □R
Breath Sounds: □ L__________ □ R__________
□BVM □CPAP/BIPAP
□Ventilator
□ R – Size: _____ Depth: ______ cm
□ 3- sided dressing
□ NML
□Bronchodilator
Skin: □ Warm □ Dry Access: □IV: Loc ___________ Size _____

C irculation
□ Pale □ Cyanotic □ Moist □ Cool
Capillary refill: □ <3 sec or ______ sec
Pulses: □ Weak □ Asymmetric______
□CVL: Loc ______ Size _____ □IO: Loc _______ Size _______
□IVF:__________mLs
□Blood ordered
□NS □LR □Other _____________
□Epinephrine given
□ NML
JVD: □ Yes □No
□A □V □P □U Blood Glucose: □ Glucose □ Naloxone
□ Moves all extremities or □ Deficit: □ Antiepileptic
Disability _________ □ Others:
□ NML Pupils: Size: L _________ R ___________ (Abnormal if < 3.5 mmol/dl)
Reactivity: L _________ R ___________

HISTORY OF PRESENT ILLNESS:

(Symptoms, time course, exacerbating and alleviating factors, prior episodes & prior interventions, including any primary health care)

REVIEW OF SYSTEMS: (See Reference Card for normal findings. Do NOT mark normal unless all key elements are normal.)
□ NML General: □ NML Reproductive:
□ NML HEENT: □ NML Skin:
□ NML Resp: □ NML MSK:
□ NML CV: □ NML Heme:
□ NML GI: □ NML Neuro:
□ NML Pelvis/GU/Rectal: □ NML Psychiatric:
 PAST MEDICAL HISTORY: History obtained from:

Chart to be used with WHO Reference Card. See who.int/emergencycare for more information.
Medications: □ Unknown Allergies: □ Unknown

Last Menstrual Cycle: _________________ G____P____ □ Unknown

Past Medical: □ HTN □ DM □ COPD □ Psych □ Renal Disease □ Unknown Pregnant? (circle) Yes / No □ Reported □ Testing done
Other: Vaccinations up to date? □ Unknown □No □Yes ________________
Substance Use: □ Tobacco □ Alcohol □ Drugs □ IV Drugs □ Unknown
Past Surgeries (type & date): □ Unknown Family History: ____________________________________________
Safe at home? _____________________________________________

PHYSICAL EXAM: (See Reference Card for normal findings. Do NOT mark NML unless all key elements are normal. Specify L or R if needed.)
□NML General □NML Cardiac

□NML Neuro/Psych □NML Abdominal

Pelvis/GU/
□NML HEENT □NML
Rectal

□NML Neck □NML Lymph

□NML MSK
□NML Respiratory
□NML Skin

DIAGNOSTICS: (Labs, Imaging)

CBC: Lytes/Cr/glucose: UPT: □ Pos □Neg Other labs/imaging:
Hbg Malaria: □ Pos □Neg
Na Cl BUN HIV Rapid: □ Pos □Neg
WBC Plt Glucose
K HCO3 Cr Blood type: ____________
Hct
□ Result pending ECG: Rate: ______
□ Result pending
Sinus rhythm? □ Y □ N
Urine Dip: Glu: Ket: Blood: Ischemia? □ Y □ N
Nitr: Leuk: Prot: Interpretation:

ADDITIONAL INTERVENTIONS:
Fluids and Medications Given Time (24h) Procedures (include time and outcome) Time (24h)
□ IVF: ______ mLs □NS □LR □Other ________ ____:____ □ Intubation: _________________________________________ ____:____
□ Blood products (specify number of units given): ____:____ □ Chest Tube: _________________________________________ ____:____
_______________________________________ ____:____ □ Lumbar Puncture: ____________________________________ ____:____
□ Opioid Analgesia:_______________________ ____:____ □ Simple / Complex Laceration Repair: _____________________ ____:____
□ Other Analgesia:________________________ ____:____ □ Other:
□ Sedation/Paralytics:_____________________ ____:____
□ Antimicrobials:_________________________ ____:____
□ Tetanus: ______________________________ ____:____
□ Other:
ASSESSMENT (include summary and differential) AND PLAN (imaging; meds/interventions; consults with time called/arrived and recs):

REASSESSMENT at _ _ : _ _ (24h) □ Condition same

Temp:_____ Pulse:______ BP:____ / ____ RR:_____ SpO 2:____ % on______ Changes:_____________________________
DISPOSITION: Checklist completed: □ Y □ N ED departure (date & time): DD/MM/YY ___ ___ : ___ ___ (24h)
Diagnoses/Impressions (list all):

□ Admit to: □ Ward ________________ □ ICU □ OT

□ Discharge: Plan discussed with patient? □ Yes □ No
□ Transfer to: ________________________________ VS at Dispo at: : (24h)
□ Left without being seen or before treatment complete Temp:____ Pulse:____ BP:____ / ____ RR:____ SpO 2:___ % on_____
□ Died of (specify cause - NOT cardiopulmonary arrest):
______________________________________________ Accepting Provider: ____________________________
Emergency Unit Provider Name/Title (include handovers) Signature and Date