Acute Care 44: Trauma Flow Sheet
Patient Name ___________________________________________________ Date ______________________
MR#_____________________________ DOB_____________________ Band # _________________________
Date of Arrival ___________________________ Time of Arrival ____________________________________
Pre-Hospital Information
Injury
_________________ Injury Time ___________________ Location of
Injury
________________ Pre-Hospital Report/Information Time of Arrival at Scene Trauma Alert Called? ![]() ![]() |
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Method of Arrival | Prior to Arrival | ||
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Mechanism of Injury
|
![]() ![]() Caliber______ Gauge_______ Range_______ ![]() ![]() ![]() |
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Safety
Restraints![]() ![]() ![]() ![]() ![]() |
Impact![]() ![]() ![]() ![]() ![]() ![]() ![]() |
![]() ![]() ![]() ![]() ![]() > 20 minutes ![]() ![]() |
Other Information Relevant to Patient's Injury |
Pertinent Health History
Past Medical History ![]() |
Medications![]() |
Allergies![]() |
Date Last Tetanus _______________ ![]() LMP___________ ![]() Last Meal_______ |
Initial Nursing Assessment BP____P____R___ T____ (Oral/Axillary/Tympanic/Rectal) % Sat___________ |
Primary Assessment | Intervention | Notes | |
Airway | ![]() ![]() ![]() ![]() ![]() ![]() ________________ |
![]() ![]() ![]() objects ![]() ![]() |
|
C-Spine | ![]() implemented ![]() ![]() ![]() ![]() ![]() _______________ |
![]() maintained ![]() applied via _________ ![]() ordered ![]() Time______ By_______ ![]() prior to transfer |
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Breathing | ![]() (record rate in VS) ![]() ![]() ![]() ![]() ![]() ![]() Deviation ![]() ![]() ____________________ |
![]() ![]() ![]() ![]() ![]() ![]() Additional interventions (chest tube) are documented in procedures. |
|
Circulation | ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() _______________ ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
![]() Bleeding Sites Location _________________ ![]() IV Sites (2 Large Bore) Site/Gauge/Time/By R______________ R______________ L______________ L______________ |
Disability/ GCS |
Eyes![]() ![]() command ![]() ![]() ![]() Medically paralyzed |
Verbal![]() ![]() ![]() ![]() sounds ![]() ![]() Intubated/Paralyzed |
Motor![]() ![]() ![]() Withdrawal ![]() ![]() Abnormal ![]() ![]() Medically paralyzed |
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Secondary Assessment
Head/Neck | ![]() |
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Chest | ![]() |
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Abdomen/Pelvis | ![]() |
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Extremities | ![]() |
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Back | ![]() |
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Neurological | ![]() |
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Physician Orders
Lab
![]() ![]() ![]() ![]() # units_____ ![]() ![]() ___________ |
X-Ray![]() table lateral C-spine ![]() ![]() spine and chest) ![]() ___________ ___________ |
Medication![]() ![]() ![]() ____________ ____________ ____________ ____________ ____________ ____________ |
IV![]() sites ![]() ![]() |
Other![]() _________ ![]() ![]() ![]() ![]() ![]() _____L via _____ ![]() min ![]() |
Physician Signature Authenticating Orders: |
P R O C E D U R E S |
RSI Meds Dose/Route ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
Intubation![]() ![]() Size: ________ |
Chest Tube ![]() ![]() R size: _______ L size: _______ |
Foley Size ____ |
NG Size ____ |
Wound
Care ![]() ![]() ![]() (specify) __________ __________ |
Gastric
Lavage ![]() ![]() |
Time | |||||||
By |
Monitoring Flowsheet
Time | ||||||||||||
BP | ||||||||||||
Pulse | ||||||||||||
Resp Rate | ||||||||||||
Temp | ||||||||||||
O2 Sat | ||||||||||||
O2 | ||||||||||||
LOC | ||||||||||||
Pain (0/10) |
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IV | ||||||||||||
Cardiac Monitor |
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Warm
Blankets |
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Bar
Hugger |
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Position
of Comfort |
Nurse's Notes
Time | |
Disposition and Destination
Admitted to: ![]() ![]() ![]() ![]() Transferred to: _____________________________ Discharged to: ![]() ![]() Transported by: ![]() ![]() ![]() ![]() Report called to: ____________________________ By: ___________________________ Time: _______________________ Discharge Assessment: BP ______ P_______ RR _______ GCS _______ (E) _______ (V) _______ (M) _______ Other: _________________________________________________________________________________________________ _______________________________________________________________________________________________________ Condition @ Discharge: ![]() ![]() ![]() Time of DIscharge: _________________________________ Belongings (list):_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________ ![]() ![]() ![]() ![]() |
Family Information
Notified?![]() ![]() |
Primary Nurse______________________________ Assisting Nurse_____________________________ Anesthesia:________________________________ X-Ray_____________________________________ EMT______________________________________ EMT______________________________________ |
Doctor___________________________________ Assisting Nurse___________________________ Lab_____________________________________ EMT____________________________________ EMT____________________________________ Recorder_________________________________ |
Other________________________________________________________________________________ |
Acknowledgement
This form has been adapted from Mercy Hospital and Health Care Center
in Moose Lake, Minnesota.