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- <br />-. ==-== ·== !_ == --~ <br />I~-114C\5 <br />UNNERSITY of CALIFORNIA, IRVINE· HEALTHCARE <br />EMERGENCY DEPARTMENT TRAUMA FLOWSHEET <br />• • ~ <br />.,L.~~Jil;~~~=----'x---::=:-----Tlme:-·--~--. <br />.. ';:· f;.~J.·. <br />,· ~ D,--a_t_a_: '""-------,------~"':;T'lr-----r.-D_O_B_:-=:==-'=-=----'-=:::-=--"t>1' 0. ·, <br />Special Circumstances:_ Custody <br />' . . . .· ;.~ .. =:' '•. ' _ Cr1me VicUm _ lnctustr1al Injury <br />. :·;,,-.. - <br />Cl ,o-es <br />' !;~~f.~ <br />•• PCP: --------'~--------Called: Y N <br />Language : (M.,~ Interpreter. ___ \ __ _ <br />Chief Complaint: <br />Medications: \)'('-~ <br />Allergies: ~ ~ <br />PMH: HTN Asthma Diabetes COPD <br />Cardiac Pacemaker Cancer • GI GU <br />Renal Seizures Arthritis ~TOH <br />Literacy: O WNL O Deaf O Other.___ Advance Directive Domestic Violence 0 <br />Leaming: 0 WNL O Blfnd O Language Barrteri--__ Y_N ________ Y __ N __ ~ <br />Psych None Unknown ~r1es <br />Other/Details _________ _ <br />Psych/ <br />Soclal : <br />O System lntact O Homeless <br />0 Famlfy Cr1sls O WNL <br />I-=============~ Self Care: 0 Able O Needs Help O Child <br />□Unable Last Tetanus: < > 5 yrs UNK <br />LMP : _________ _ <br />O Motor V~lcla Crash <br />ODr1ver <br />O Passenger <br />O Ejected Thrown ___ ft, <br />O Restrained O Unrestrained O Unk <br />□Car Seat <br />O Nrbag Deployed O Froot O Side <br />O Motorcycle Crash <br />O Helmet O No Helmet O Unknown <br />0 Auto/Ped MPH ____ _ <br />Thrown ____ ft. <br />O Bicycle/Skateboard <br />O Burn ~\r l _,. <br />SW Locatlo • '4lV\:tnt,\.l <br />tab Wound Lo~~m: ___ _ <br />Remarks:_( __________ _ <br />00-10 <br />Motor Response <br />Verbal Responu <br />OFacss <br />Spontaneous <br />To Voles <br />To Pain <br />More <br />Obeys Command <br />Locallzes to Pain <br />Withdrawal Pain <br />Flexlon Pa in <br />Extension Pain <br />None <br />Oriented <br />Confused <br />Inappropriate words <br />lncomp words <br />None <br />Normal O Whlmper1ng <br />Moaning High pitched <br />Activity Leval: O Playful O Fus Quiet <br />Fontanels: 0 Flat O Bulging O Sunken <br />Wt: <br />E <br /> <br />ssault lr-~"":'11=--::-,::r.:----._:-:--"!",>-.---,,<"'"'l!!"'-+-+--+--- <br />0 Falf ___ ft. <br />0 <br />• NURSING DIAGNOSIS N <br />~ (R/T =RELATED TO) <br />1 Airwav Clearance RT 13 Knowfedoe Deficit R/T <br />2 Anxiety R/T 14 • Mobrntv lmoalred Phvalr_al R/T <br />3 Body Temoeratur.e, Altered R/T 15 Pain Acute/Chron~ R/T <br />4 Breethina Pattem Ineffective R/T 16 Post Trauma Resoonse <br />5 Cardiac Outnut, Decreased Kil ·-17 Raoe Trauma Resnnn"" <br />6 CommunlcaUon lmcairad, Verbal R/T 18 Skin lnl"""IV Imo.aired <br />7 Fear R/T 19 Thno ~ht Processes AJter&d <br />8 Fluid Volume OeficiVExcess/Aciual/Poterrtlel 20 Tlssue lnleorltv. lmoalred <br />9 Gas Exchanqe, Impaired R/T 21 Tlssue Perfusion Altered <br />1 O Grieving R/T 22 Urinarv Elimination Altered <br />11 lnrection, PotentlaVActual R/T 23 Vlolence, Potential For <br />12 lniurv, Potential For 24 Other <br />All documentation must indicate the specific date and time of entry and a signature <br />complete with identifying credential, tiUe or classification. <br />87304 (Rev 8-18-10) p 1 of 2 <br />Orthopedic Consult