Ed Trauma Flow Sheet Page 5
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2
3
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5
6INTAKE
OUTPUT
IV# / AMT
SITE
SOLUTION
TIME UP
BY
TIME DOWN
TOTAL
TIME / AMOUNT
TIME / AMOUNT
URINE:
GASTRIC / LAVAGE:
L CHEST:
R CHEST:
EMESIS:
TOTAL:
TOTAL INTAKE AND OUTPUT
INTAKE:
OUTPUT:
IV:
FOLEY:
BLOOD:
GASTRIC:
ORAL:
CHEST TUBE:
OTHER:
OTHER:
OTHER:
OTHER:
TOTAL:
TOTAL:
MONITOR STRIP
DISPOSITION:
ADMITTED:
DX:___________________________________
ATTENDING:_______________________________
TIME ADMIT CALLED: ____________________________
ROOM #: __________________________________
TIME REPORT CALLED:___________________________
TO:_______________________________________
TIME LEFT ED: ______________________
O
RN
2
BELONGINGS: ________________________________________________________________________________________
TRANSFERRED:
TO:___________________________________
VIA: ______________________________________
BELONGINGS: ________________________________________________________________________________________
TIME LEFT ED: ___________________________________
TRANSFER FORM COMPLETED:______________
DEATH:
TIME OF DEATH:_________________________
PRONOUNCED BY: _________________________
TIME PMD NOTIFIED: _____________________
CODE BLUE SHEET COMPLETED: ___________________________
TIME CORONER NOTIFIED: ________________
SIGNED DEATH CERTIFICATE?
YES
NO
DONOR FORM COMPLETED:
YES
NO
WRTC NOTIFIED:
YES
NO
TIME BODY MOVED: _____________________
CORONER
MORGUE
POLICE/HOMICIDE:
TIME NOTIFIED: _____________________
TIME RESPONDED: ______________________
MD SIGNATURE: _________________________________
PRIMARY NURSE'S SIGNATURE /
DATE: ______________
TITLE: ___________________________________________________
PART OF THE MEDICAL RECORD
8850011 Rev 05/05
PAGE 5 of 6
ED Trauma Flow Sheet_EMERGENCY ROOM
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