2.  Date/Time/Onset of illness or injury  Methods of Arrival and with whom  Condition on arrival an Level of Consciousness  Triage level upon arrival  Any treatment prior to arrival  Assessments, problem list, plan  Time and Initials with all written entries and corresponding signature  Document tetanus history of all breaks in the skin, burns and nose bleeds, abscesses, fractures, MVC’s, eye injuries, subungual hematomas, dental  Current Medication and Allergies including dosages and frequency  Wrights on all patients. Estimated wrights on patients over 18  When documenting medications given document name of med, time, route, site and a recheck of vital signs within 20 minutes, sooner if medication mandates  IV’s 18 gauge preferred, document site, patency, # of attempts, fluid and rate  O2 saturations to be obtained on all respiratory complaints on room air, how much o2 applied, breath sounds and quality of respirations  Pain assessment scale  Vital signs-a full set on all adult patients and individuals who weigh greater than 100 pounds, record route of temperature, quality of pulse etc.

3.  Adult Recheck If:  BP Systolic greater than 160 and diastolic greater than 90 or systolic less than 90 or diastolic less than 60  Pulse rates greater than 100 or less than 50  Respirations greater than 30 or less than 12  NOTIFY MD if heart rate greater than 130 or less than 50, pressure systolic greater than 200 or less than 90, diastolic pressure greater than 100 or less than 40, respirations greater than 24, temp greater than 103 or less than 96 and pulse ox less than 90

4.  All auto accident victims  Overdoses  After receiving medications (within 15-20 minutes)  Asthma therapy including aerosols  All injections  After pelvic examinations  Admissions to the hospital  Every hour at a minimum while the patient remains in the department  Head injuries

5.  FSBS on ALL diabetic patients  Any decreased LOC  Light headed  Dizzy  Syncope  Confusion  Comatose from unknown etiology  Possible CVA

6.  All MVC’s  Trauma Acutely Ill  Abdominal Pain  Suicide Attempts  Give a sheet to ALL patients  Secure all clothes in a belonging bag with a patient label and chart in IBEX

7.  Document all notifications of deaths, disposition of the body and the personal belongings

8.  Who and how the patient was discharged  i.e. to work, to who pt discharged, etc.  Was there an eye patch applied, was medication given, was there a BAL documented and is the patient OK to drive etc.

9.  Report must be called on all patients including patients returning to the nursing home  Include family doctor and any specialists the patient sees  Was this a work related injury-complete forms and contact worker’s comp to verify

10.  Weight in kilograms  Head circumference if Hydrocephalus or physician request  Pain assessment appropriate for age  Immunization status  Undress and expose injured part  Vital signs – temp, pulse and respirations if under 12  Blood Pressure on ALL head injuries  If under 1 document formula or breast, birth weight, section or vag delivery  Pulse ox and smokers in the home, especially on respiratory complaints

11.  Determine level of conscious ness  Ability to follow commands  Moving all extremities  Mechanism of injury  Pupil check  History of headaches  Serial vital signs

12.  Time of onset – last known well  NIH stroke scale assessment  FSBS  Medications  Past Medical History  MD to room ASAP  REMEMBER TO ACTIVATE THE RRT AND DOCUMENT THAT YOU DID SO

13.  Completely undress  Driver, passenger, front or back seat  Seat belts  Air bags deployed  Pupil check  Full set of vital signs  Tetanus history  Mechanism of injury  Mode of arrival  Immobilization in place  Repeat vital signs

14.  Undress  Full set of vital signs  Time of ingestion, amount, substance  Suicidal ideation or accidental  LMP  Serial vital signs  Any emesis or treatment prior to arrival- if emesis describe amount and if any pill particles are present  Lavage-route of tube, proper placement, ml’s instilled and returned  Airway management  LOC

15.  Visual Acuity – ON ALL EYE COMPLAINTS  Treatment prior to arrival  Pupil check  Tetanus status  Minimal of 500 ml saline each eye flush with chemical injury  Glasses or contacts-remove contacts  Document all patches and medications administered in the ED

16.  Full set of vital signs with Pulse Ox  Breath sounds and quality of respirations  Home o2  Date/time onset of symptoms  Productive cough  Flu/Pneumonia vaccine  Recheck of vital signs and breath sounds after treatment or medications

17.  Onset of symptoms  Any injury  LMP  Last bowel movement (normal, constipated, loose)  Nausea/Vomiting/Diarrhea or Fever  Urinary symptoms

18.  Document deformities, bruising, swelling  Documentation of pulses  Neurovascular checks before and after splinting  Remove ALL jewelry from injured extremity  Tetanus status  Ice/Elevate  Last time patient ate  Weight