EMERGENCY INITIAL ASSESSMENT FORM TT Mass Casualty CRN: Date: D/A Time of Arval em Patient Name ee: ‘Arival Mode: Ambulance Car/Truck cle Private or Tax) Motorized 2/3wheeler (ce Private or Tax) ine fH / a0 | © ‘Gender-cMale afemale | Dateof Birth: f Public Transport_pWalk_c Other: Other: fran Weight: 6} Number of prior facilities: ‘Occupation: 0. Unknown: Referred from: Patient Residence (t less cy ad Sub st Unknown _[ ambulatory Non Ambulatory: a Aeute a Chronic Contact Person Phone Relation CHIEF COMPLAINT: Triage Category: INITIAL Vitals at am @® @® ® @® Temp: arf Pulse RR: OD @ ~~, 9 & Sp0xi__%on Pain score. 710 = i TREATING PROVIDER ASSESSMENT: Date: bofvinifY Time: (2th) Dead on arrival HIGH RISK SIGNS Abnormal AVPU. 1 HR <55 or >130 (adult) 1 Strider, voice change or unable to swallow 1 Poor perfusion, weak pulse, capillary ref >35 Temp >39°C or 6° 1 $02 <90% on RA "Respiratory distress (grunting in child, retractions, cyanosis) Vormts everything, can't drink or feed PRIMARY SURVEY: (ce Reference Card for normal ndings, only mark NM fall Key efemens ate normal) BAngioedema “a Strdor GVoice changes Tpirway: SRepostioning OSuction COPA ONPA GLMA Bawa 1 Oral/Airmay burns ae cer irway | obstructed by: a Tongue 0 Blood a ecretions oNML Vomit _a Foreign body Spontaneous Respiratory Rate: ‘Onvee T ‘Chest needle or tube (cre Chest Rise: Shallow oRetractionso Paradoxical | NC cM@osk cWRa GL Size:___ Depa em Beating | teacher a maine Devoted ont on | ani aceanyapae | oR ~ Snes ——epth’_——em Breath Sounds: 3 ventilator 3 sided dressing bNML ____ Mt Bionchedtor Skin: Warm airy "accesso Loe Sie Pale v Cyanotic © Moist 9 Cool DCL Loe Site___ 510° Toe size Cciason | capitary rei 23sec 0 we one ms ORS ale ater ; Pulses: © Weak a Asymmetrie (Blood ordered bépinephrine given nae NvD:= Yes oN TA CV OP OU Blood Glucose: Glocose 1 Naloxone D. 1 Moves all extremities or Defi Antieple isabitty Others: Papi Se: R te —— *§___ (Abnormal f<3.5 mmo Reactivity: R v M HISTORY OF PRESENT ILLNESS: (Symptoms, time course, exacerbating and allevating factors, rior epsodes & prior ntrventons including any primary eal care) REVIEW OF SYSTEMS: {See Reference Card fr normal finings. Do NOT mark normal unlessalkey elements are normal) aNML | General DML | HEENT: DNML | Resp: DNML. | cy: nNML | Gl: INML | Pelvis/6U/Rectal: ENML | Reproductive: ONML | Skin ONML | MK: ONML | Heme: ONML | Neuro: ONML | Psychiatric: ® GARG VISIONARY MULTISPECIALITY HOSPITAL "A Unit of Dr. Nitin Garg Ortho ContrePAST MEDICAL HISTORY: History obtained from: Medleations Past Medical: HIN 10M <1 COPD = Payeh Unknown Renal Disease Unknown Allergies: ‘BUnknown Last Menstrual Cycle: Pregnant? rl) Yes 7 NO P__oUnkxown Reported Testing dane Saat wt ] cena | crac wn | necoaren yt | Abort wa | wen coon | PEMBTSUT wn | nek co | mph aa | wa nt | Rept piratory aNML | Skin DIAGNOSTICS tam mage oe eer Wr cho aig eth blige tae po ap Mead tac ag Sood "ADDITIONAL INTERVENTIONS Fis and ecko Gen Tee Bat) Poser Ins neo ome To an Spor hatea oS ater Rep ronan senmraa ie ASSESSMENT [as oO SAND PLAN SG TORS REASSESSMENT at 24h} Condition same . DISPOSITION: Checklist completed: OY 3 ED departure (date & time}: MM (24h) goss /impreions tl caadnita: Ward amy aor Clinic Sangueenorbcoawemmencanie | Temp Puig SRL RR:_Sp0s_won_ "Died of (specify 2USe - NOT cardiopulmonary arrest) Accepting Provider: Energeney Unit Provider Name/Title include handover) ‘Signature and Date é GARG VISIONARY MULTISPECIALITY HOSPITAL "A Unit of Dr Nitin Garg Ortho Cent