Example

Emergency Services Trauma Flow Sheet

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 _________________ Truck ATV
Physician / CNP / PA Motorcycle Boat
Lab Bicycle
X-ray Other_____________________________________
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

Stabbing Crush Heat exposure Near drowning

Height____________ ft. Other Other

Cold exposure Animal related
 Example
Emergency Services Trauma Flow Sheet

Initial Assessment
AIRWAY DISABILITY
Patent Suctioning Glasgow Coma Score Initial Disch
Oral Airway Bag Mask Eye Opening
Nasal Airway O2 __________________ L. Spontaneously 4
ET ________________ Comments To Speech (Shout) 3
Trach To Pain 2 ______ ______
Crico _____________________________________ No Response 1
BREATHING Verbal Response
Spontaneous Respiratory Effort Oriented (Coos, Babbles) 5
R L 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
Decreased Intercostal Paradoxical Words (Grunts, Restless)
Absent Substernal Cough No Responses 1 ______ ______
Smoker Yes No Unk Motor
CIRCULATION Obeys (Spontaneous) 6
Capillary Refill: None Delayed (> 2 sec) Normal (< 2 sec) Localized Pain 5
Pulses Present: Carotid Femoral Radial Pedal Withdrawal to Pain 4
Palpated Pulse Regular Irregular Flexion to Pain 3
Heart tones Audible Absent (Decorticate)
Jugular Vein Distension No Yes Extension to Pain 2
Bleeding Controlled Uncontrolled NA No Response to Pain 1 ______ ______
Skin Color Pink Dusky
Pallor Cyanotic Total GCS Score ______ ______
Flushed Mottled

Area of Injury
Allergies
:
Tetanus: ________ LMP:_________ Wt: ___________
Procedures
Time Procedure Results
ET Tube _____ Combitube ____ Size ______________________
Secured @ ______________cm
FiO2 ___________________ %
Central Line/ IV Size ____________________ Fr
Site _______________________
Solution___________________
Warming Measures Fluids
Mechanical
Bair Hugger
Blankets
NG Tube Size _____________________
Color____________________
Foley / Quick Cath Size ____________________ A = Abrasion Fc = Closed OW = Open
Color____________________ Fracture Wound
Neck immobilization CMS: B = Burns Fd = Dislocation P = Paralysis
C-Collar Applied: ___________ Before___________________ C = Crepitus Fo = Open Fracture S = Edema
__________________________ After ____________________ D = Deformity L = Laceration Ta = Total
Amputation
Splinting _________________ Location:__________________ E = Ecchymosis Na = Near
_________________________ Amputation
 Example
Emergency Services Trauma Flow Sheet

Secondary Assessment
Head/Scalp Eyes Mouth Ears
Intact Rash PEARL Intact No drainage
Laceration Burns Raccoon eyes Teeth Drainage
Abrasions Pain EOMS follows Missing teeth Right Left
Bruising Battle Visual Acuity OD ____/____ Dentures intact Clear Clear
Signs OS ____/____ Comments_________ 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 Location _____________ Activity @ onset ________
Sub-q emphysema Crepitus Flail chest
Difficulty swallowing Location_____________ Other _________________
Abdomen / Pelvis / GU
Abdomen Bowel Sounds Pelvis
Soft Distended Last Intake: Present Intact
Nontender Rigid Food ________________ Absent Pain ______________________
Tender Liquid _______________ Hyperactive ____________________________
Comments: Hypoactive Blood at meatus ____________
Blood at rectum ____________
Instability _________________
Posterior Extremities
Intact Intact
Deformity Fracture
Pain Pain
Comments _________________________________________ Deformity
____________________________________________________ Comments _________________________________________
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
Pupil Reaction Pain Scale Comments
S-slow U-unequal 0-10
Tem O2
Time P R BP SaO2 B-brisk D-dilated Pain
p L/min
F-fixed = - Equal
C-closed by swelling Scale Type

/ Right Left
/
/
/
/
/
/
/
/
/
/
/
Medications Given
Medication Dose Route Time Given Initials
 Example
Emergency Services Trauma Flow Sheet

Input Output
Source Prior to Arrival ED Total Source Prior to Arrival ED Total
IV Fluids Urine
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