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    Adult Triage Form Page 1

    Uploaded by

    Sivakumar Gounden
    This document is an adult trauma triage form for R.K. Khan Hospital. It collects information such as the patient's name, outpatient number, date, and time of admission. Sections are included for the patient's history, signature accepting treatment, witness signature, attending doctor's name and identification number, and time and date of treatment. A section is also included for the doctor's prescription.

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    Adult Triage Form Page 1

    Uploaded by

    Sivakumar Gounden
    386 views1 page
    This document is an adult trauma triage form for R.K. Khan Hospital. It collects information such as the patient's name, outpatient number, date, and time of admission. Sections are included for the patient's history, signature accepting treatment, witness signature, attending doctor's name and identification number, and time and date of treatment. A section is also included for the doctor's prescription.

    Original Description:

    triage form

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    This document is an adult trauma triage form for R.K. Khan Hospital. It collects information such as the patient's name, outpatient number, date, and time of admission. Sections are included for the patient's history, signature accepting treatment, witness signature, attending doctor's name and identification number, and time and date of treatment. A section is also included for the doctor's prescription.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as odt, pdf, or txt
    386 views1 page

    Adult Triage Form Page 1

    Uploaded by

    Sivakumar Gounden
    This document is an adult trauma triage form for R.K. Khan Hospital. It collects information such as the patient's name, outpatient number, date, and time of admission. Sections are included for the patient's history, signature accepting treatment, witness signature, attending doctor's name and identification number, and time and date of treatment. A section is also included for the doctor's prescription.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as odt, pdf, or txt
    of 1

    R.K.

    KHAN HOSPITAL ADULT TRAUMA TRIAGE FORM

    PATIENT NAME : ________________________________ DATE : __________________

    OUTPATIENT NO. : _______________________ TIME : __________________

    HISTORY
    __________________________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________________________

    __________________________________________________________________________________________________________________________________________________________

    ____________________________________________________________________________________________________________SIGN : _______________________________________

    I HEREBY ACCEPT TREATMENT RENDERED UPON YSELF / NEXT OF KIN : ________________________________________________________________________________

    NURSES' SIGNATURE / WITNESS : ________________________________________________________________________________________________________________________

    DOCTOR'S NAME : ______________________________________________________________ M.P. NO. : ________________________________________

    TIME : _________________________________________ DATE : ________________________________________

    ________________________________________________________________________________________________________________________

    ________________________________________________________________________________________________________________________

    ________________________________________________________________________________________________________________________

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    ________________________________________________________________________________________________________________________

    ________________________________________________________________________________________________________________________

    ________________________________________________________________________________________________________________________

    ________________________________________________________________________________________________________________________

    ________________________________________________________________________________________________________________________
    PRESCRIPTION MUST INCLUDE DOCTORS FULL SIGNATURE / QUALIFICATIONS

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