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Emergency Initial Assessment Sheet

The document is an Emergency Initial Assessment Sheet used for recording patient information upon arrival at a medical facility. It includes sections for personal details, assessment of airway, breathing, circulation, vital signs, and triage priority, as well as space for doctor notes and medication administration. The form is designed to ensure comprehensive documentation for effective patient care and management.

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laxmi hospital
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4 views3 pages

Emergency Initial Assessment Sheet

The document is an Emergency Initial Assessment Sheet used for recording patient information upon arrival at a medical facility. It includes sections for personal details, assessment of airway, breathing, circulation, vital signs, and triage priority, as well as space for doctor notes and medication administration. The form is designed to ensure comprehensive documentation for effective patient care and management.

Uploaded by

laxmi hospital
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
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ADDRESSOGRAPH

EMERGENCY INITIAL ASSESSMENT SHEET


Name: Age/Sex: Phone:
Address:
Arrival Date: Arrival Time: Arrival Mode: Ambulance / Private Vehicle / Public Transport
Referral From: Self / Physician / Other Hospital Previous Admission: Yes / No
Allergies if any:
Source of History: Patient / Family / Friends
Airway Breathing Circulation
Assessment Assessment Assessment
Management Management Management
Triage Priority: 1 / 2 / 3 / 4 / 5 Triage Done By Time:
Status before arrival: Oral airway / Nasal airway / ETT# / NTT# / RSI / CRICO / O2 _____ 1/MIN
VIA ___________________________ Breathing Sound: Lt

Vitals: Pulse: ______ /min. BP: _____/____ mmHg RR: _______ / min. SPO2: ___________ %
Pain score:
IV Fluids: RL / NS / DNS 1 2 3 4 5 Volume __________ ml
Urinary Cath / Gastric Tube / C-Spine Support / Spine Protection Time on:

Medication:

Patient identified with any kind of abuse (social, sexual etc.): Yes No
If yes, explain:
ALL CHART (monitor as per Clinical’s Instructions)
Time Temp PR RR BP SPO2 Pain Other Intake Output
Urine Stool
Eye Open Spontaneous 4 GCS Pupils
To Speech 3 E V M Rt. Pupil Lt. Pupil
To Pain 2
None 1
Verbal Oriented 5
Response Disoriented 4
Monosyllabic 3
Incomprehensible Sound 2
None 1
Motor Obeys commands 6
Response Locatise Pain 5
Flexion (withdraws) 4
Flexion (abnormal) 3
Extensor to pain 2
None 1
DOCTOR NOTES Please sign (following documentation)
NB S.A.P. = STORY-ASSESSMENT-PLAN
Pregnancy: Yes LMP ___________ No
Breastfeeding: Yes / No
Chief Complains:

Date & Time

Positive Clinical Findings:

Working Diagnosis:
Investigation: Lab

Doctor Signature
Imaging:

Final Diagnosis:

DRUG CHART
Drug Name Dose Route Frequency Dr’s sign Administered Time
By

ER
MO HAND OVER:

Ward/ICU:

MO Name: ____________________________________________________________________________

Sign: _________________________________________________________________________________

Date: ________________________________________________________________________________

Time: ________________________________________________________________________________

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