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New/Established
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HISTORIAN
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If other
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PCP
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Preferred Pharmacy
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Medical History
• • •
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If other, please list
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HPI
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Chief Complaint
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Occurred
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Occured ______ days PTA
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Location
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Mechanism of injury
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Pain of Scale (1-10)
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Pain/discomfort
• • •
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If contusion to head
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Immediate Cry?
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Loss of consciousness?
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Decreased level of consciousness since injury?
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ROS
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Abnormal findings
• • •
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Comments
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SOCIAL HISTORY
• • •
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Comments
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PAST HISTORY
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PHYSICAL EXAM
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GENERAL APPEARANCE
• • •
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Comments
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HEAD
• • •
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Comments
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NECK
• • •
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Diagram
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Comments
|
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EYES
• • •
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Comments
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If unequal pupils R______mm
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L______mm
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ENT
• • •
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Comments
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NEURO
• • •
|
|
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GCS ______ A-V-P-U
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Comments
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RESPIRATORY
• • •
|
Comments
|
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CVS
• • •
|
Comments
|
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ABDOMEN
• • •
|
Comments
|
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GENITAL EXAM
• • •
|
Comments
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RECTAL EXAM
• • •
|
Comments
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BACK
• • •
|
Comments
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Diagram
|
|
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SKIN
• • •
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Comments
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See Diagram
|
|
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EXTREMITIES
• • •
|
Comments
|
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See Diagram
|
|
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HIPS/PELVIS
• • •
|
Comments
|
|
See Diagram
|
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PROCEDURES
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Wound Description / Repair
• • •
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length____cm
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location
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Distal NVT
• • •
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Anesthesia
• • •
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If digital block____mL
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Preparation
• • •
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If irrigated / washed w/ saline
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If debrided
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If undermined
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If foreign material removed
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Repair Wound closed with
• • •
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LABS
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Comments
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PROGRESS/TRANSFER NOTES
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Time
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Comments
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ASSESSMENT
• • •
|
If other, please list
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Discharge Medication / Plan
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FAX TO PCP
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DATE
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TIME
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Counseled patient / family regarding
• • •
|
Comments
|
