Emergency Services Trauma Flow Sheet Example
Hospital Logo Patient Sticker
Date: Patient Arrival Time:
N/A Pre-Hospital Treatment
Transporting Ambulance_____________________________________________________________________________________
O2 @ ______L/min/ IV: Needle size______________ Backboard
NC NRB Ambu LR _________________ Long Short Ked
Airway Medications ________________ Scoop
Oral Nasal Other _____________________________ Bilateral Head Supports
ET tube # _____ @ _____cm C-Collar on: Yes____ No ____ Splint on _________________
Ice on __________________
CPR started @ (time)______________ Dressing ________________
Other __________________
Date of Injury: ___________________ Time of Injury: __________ Pre-hospital trauma team alert notification:
Yes No
Hospital Trauma Team Activation Yes____ No____ Time of Trauma Team Activation: _______________
Trauma Team Members Type of Vehicle
Team members notified: Time Called Time Arrived Car Pedestrian
Nurses x _________________
Physician / CNP / PA Truck ATV
Lab
X-ray Motorcycle Boat
Other ____________________
Bicycle
Other_____________________________________
Mechanism of Injury Restraint Devices
Speed of vehicle ________ MPH Rollover Lap belt Airbag deployed
Number of vehicles Ejected Shoulder belt Helmet
1 2 3 >3 Rearend Car seat Unrestrained
Steering wheel deformity T-Bone
Starred windshield Head on
Fall Penetrating Blunt Thermal Other
Fell from: GSW Assault Burn Hanging
Heat exposure Near drowning
Stabbing Crush
Cold exposure Animal related
Height____________ ft. Other Other
Emergency Services Trauma Flow Sheet Example
Initial Assessment
AIRWAY DISABILITY
Suctioning
Patent Bag Mask Glasgow Coma Score Initial Disch
O2 __________________ L. ______
Oral Airway Comments Eye Opening
Nasal Airway ______
ET ________________ _____________________________________ Spontaneously 4
Trach ______
Crico To Speech (Shout) 3 ______
To Pain 2 ______
No Response 1
BREATHING Verbal Response
Spontaneous Respiratory Effort Oriented (Coos, Babbles) 5
RL Normal Agonal Confused 4
Lung sounds Shallow Nasal flaring (Consolable, Cry)
Clear Stridor Tachypnea Inappropriate Words 3
Rales Dyspnea Grunting (Persistent Cries, Screams)
Rhonchi/Wheezes Retracting Absent Incomprehensible 2
Words (Grunts, Restless)
Decreased Intercostal Paradoxical 1 ______
No Responses
Absent Substernal Cough Motor 6
Smoker Yes Obeys (Spontaneous) 5
No Unk Localized Pain 4
Withdrawal to Pain 3
CIRCULATION Flexion to Pain
(Decorticate)
Capillary Refill: None Delayed (> 2 sec) Normal (< 2 sec)
Pulses Present:
Palpated Pulse Carotid Femoral Radial Pedal
Heart tones
Regular Irregular
Jugular Vein Distension
Audible Absent
Bleeding
Skin Color No Yes Extension to Pain 2
No Response to Pain 1 ______
Controlled Uncontrolled NA
Pink Dusky
Pallor Cyanotic Total GCS Score ______
Flushed Mottled
Allergies Area of Injury
: Fc = Closed
Fracture
Tetanus: ________ LMP:_________ Wt: ___________ Fd = Dislocation
Fo = Open Fracture
Procedures L = Laceration
Time Procedure Results
ET Tube _____ Combitube ____ Size ______________________
Secured @ ______________cm
FiO2 ___________________ %
Central Line/ IV Size ____________________ Fr
Site _______________________
Warming Measures Solution___________________
Fluids
Mechanical
Bair Hugger
Blankets
NG Tube Size _____________________
Color____________________
Foley / Quick Cath Size ____________________ A = Abrasion OW = Open
Wound
Color____________________ B = Burns
C = Crepitus P = Paralysis
Neck immobilization CMS: D = Deformity S = Edema
C-Collar Applied: ___________ Before___________________ Ta = Total
Amputation
__________________________ After ____________________ Na = Near
Amputation
Splinting _________________ Location:__________________ E = Ecchymosis
_________________________
Emergency Services Trauma Flow Sheet Example
Secondary Assessment
Head/Scalp Eyes Mouth Ears
PEARL
Intact Rash Raccoon eyes Intact No drainage
EOMS follows Teeth
Laceration Burns Visual Acuity OD ____/____ Missing teeth Drainage
Dentures intact
Abrasions Pain OS ____/____ Comments_________ Right Left
Bruising Battle Clear Clear
Signs Blood Clear
Neck Chest Heart Sounds
Intact C-Collar Symmetrical Chest Pain Present
Swelling Pain Asymmetrical Location_______________ Distant
Trachea midline Paradoxical movement Time of onset ___________ Absent
Trachea deviated
Sub-q emphysema Location _____________ Activity @ onset ________
Difficulty swallowing Crepitus Flail chest
Other _________________
Location_____________
Abdomen / Pelvis / GU
Soft Abdomen Last Intake: Bowel Sounds Pelvis
Nontender Food ________________ Intact
Tender Distended Liquid _______________ Present Pain ______________________
Comments: Rigid Absent
Hyperactive ____________________________
Hypoactive Blood at meatus ____________
Blood at rectum ____________
Instability _________________
Posterior Extremities
Intact
Deformity Intact
Pain Fracture
Comments _________________________________________ Pain
Deformity
____________________________________________________ Comments _________________________________________
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
Pupil Reaction Pain Scale Comments
Time Tem P R BP SaO2 O2 S-slow U-unequal 0-10
p L/min B-brisk D-dilated Pain
F-fixed = - Equal
Scale Type
C-closed by swelling
/ Right Left
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Medications Given
Medication Dose Route Time Given Initials
Emergency Services Trauma Flow Sheet Example
Source Input Total Source Output Total
IV Fluids Prior to Arrival ED Urine Prior to Arrival ED
Emesis
Chest Tube
Other
Blood
Fresh Frozen Plasma
Personal Belongings
Clothes
Purse
Wallet
Jewelry ____________________________________________________________________
Given to:
Name ________________________________________________________________________
Relationship __________________________________________________________________
Nursing Staff __________________________________________________________________
Nurse Notes:
RN Signature: ______________________________________________________________________________
Q/trauma2/trauma/trsystemdevelopment/sdtaskford/flowsheetdraft/09-09
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Emergency Services Trauma Flow Sheet Example Initial Assessment . AIRWAY . DISABILITY Patent Suctioning; Glasgow Coma Score . Initial ; Disch
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