Affix Patient Label Affix Patient Label

Emergency Nursing Emergency Nursing

Emergency Department
Care Record Care Record
Emergency Department
600 University Avenue
600 University Avenue
Toronto, Ontario, Canada M5G 1X5
Toronto, Ontario, Canada M5G 1X5
Form MS 560 TRIAL (Rev 10.2010) Form MS 560 TRIAL (Rev 10.2010)

Page 4 of 4 Page 1 of 4

Time Date _________________________ Time _______________________

(HH:MM) Progress Notes YYYY MM DD HH.MM

Room ________________________
Presenting Health Problem Health History/Allergies
Smoker ■ Yes ■ No

■ Brought in by police: Badge # ■ Security arrived to bedside: Time _____________ HH.MM

• Airway • Pain ■ N/A

■ Patent ■ Compromised Location _____________________ Radiation _______________________
• Breathing Quality _______________________ Time of onset ___________________
HH.MM
■ No respiratory distress ■ Mild distress Provoked by / Alleviated by _________________________________________
■ Moderate distress ■ Severe distress Pain Score _______________ /10
• Breath Sounds
■ Equal, clear bilaterally ■ Crackles ■ Wheezes • Symptoms ■ N/A
Nausea _______________________ Vomiting ________________________
■ Other _________________________________________________________
Diarrhea _______________________ Last bowel movemt ______________
• Circulation YYYY MM DD HH:MM

Skin colour________ Skin temperature________ Diaphoresis________ • Social Situation Language Spoken ______________________________
• Radial Pulse ■ Interpretation Services contacted
■ Strong ■ Regular ■ Weak ■ Irregular ■ Lives with family / friend ■ Lives alone ■ Has CCAC
• Hydration ■ Other _________________________________________________________
■ Well hydrated ■ Mild dehydration Clothing / Belongings / Own Medications given to:
■ Moderate dehydration ■ Severe dehydration ■ With patient ■ Family ■ Security ■ Other ________________
• Neurologic ■ Awake, alert and oriented • ISAR (For all Patients >65) ■ N/A
■ Altered LOC (See Neuro Vital Sign Record, page 3) 1) Before the illness or injury that brought you to the Emergency, ■ Yes 01
did you need someone to help you on a regular basis? ■ No 00
• Abdomen ■ N/A
2) In the last 24 hours, have you needed more help than usual? ■ Yes 01
Bowel Sounds ________________ Distention _______________________
■ No 00
Guarding _____________________ Rigidity __________________________ 3) Have you been hospitalized for one or more nights during the ■ Yes 01
past six months? ■ No 00
• Genito-Urinary ■ N/A
4) In general, do you have problems with your vision? ■ Yes 01
Dysuria _______________________ Hematuria _______________________ ■ No 00
Frequency ____________________ Flank pain ■ Right ■ Left 5) In general, do you have serious problems with your memory? ■ Yes 01
■ No 00
• Gynecologic ■ N/A 6) Do you take six or more medications every day? ■ Yes 01
■ No 00
Last menstrual period _________________ Gravida/Para ______________ Positive test is 2 or more
YYYY MM DD Total /6
Vaginal bleeding Amount _______________ Duration _______________

Initial Assessment by ____________________________________ , RN

Signature of Nurse
 Affix Patient Label Affix Patient Label

Emergency Nursing Emergency Nursing

Care Record Care Record
Emergency Department Emergency Department
600 University Avenue 600 University Avenue
Toronto, Ontario, Canada M5G 1X5 Toronto, Ontario, Canada M5G 1X5

Form MS 560 TRIAL (Rev 10.2010) Form MS 560 TRIAL (Rev 10.2010)

Page 2 of 4 Page 3 of 4

Interventions CBGM Vital Signs

Time Time

Temperature
Intravenous Initiation Gauge Intravenous Location Initials Value Initial Pupils

Coma Scale
Respiratory
(HH:MM) (HH:MM)

+ / - CAM
Strength

Heart Rate
Pupils (size in mm)

Pressure

Glasgow
Site #1 L R

Cardiac
Rhythm

Oxygen
LPM %
1 2 3 4

Verbal

Motor
Blood
Arm Leg

SpO2

Eyes
Rate

Pain
Site #2 Time Size React Size React
(HH:MM) mm + / - mm + / - R L R L Initials
Site #3 5 6
Site #4
Time Interventions Size Site / Comments / Drainage Initials
(HH:MM) 7 8
Urinary Catheter
Gastric Tube
Central Line
Eyes
Arterial Line 4 = Spontaneous
3 = To voice
2 = To pain
Intravenous Intake 1 = None
Time End Time Time S = Swollen shut
(HH:MM) Site # Bag # Solution Volume Rate (HH:MM) Initials (HH:MM) Intake Output Initials
Verbal
5 = Oriented
4 = Disoriented
3 = Inappropriate
words
2 = Incomprehensible
sounds
1 = None
T = ET Tube/Trach

Motor
6 = Obeys commands
5 = Localizes pain
4 = Withdraw pain
3 = Flex to pain
2 = Extend to pain
1 = None

Strength
N = Normal
W = Weak
A = Absent

Transfer Summary
Date (YYYY.MM.DD) Time (HH.MM) Unit Report given by Report given to
Medications
Time Medication Dose Route Initials Time Effect Initials
(HH:MM) (HH:MM)

Discharge Summary
Date (YYYY.MM.DD) Time (HH.MM) Accompanied by Method of transportation

Follow-up Plan

Written Instructions

Health Teaching

Discharge Nurse

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