Triage Category

REGION II TRAUMA AND MEDICAL CENTER Green Yellow Red

National Highway, Bayombong, Nueva Vizcaya Health Record No.:

TRAUMA EMERGENCY RECORD MEDICO-LEGAL:  Yes  No

Patient’s Name: (LAST) (GIVEN) (MIDDLE)

Birth Date: ____ / ____ / ____ Age: Sex:  Female Current Address Telephone No.
mm dd yyyy  Male
Place of Injury: Date and Time of Injury Date and Time of Consultation
____ / ____ / _______ ; _______ hr ____ / ____ / _______ : _______ hr
mm dd yyyy mm dd yyyy
Injury Intent:
 Unintentional/Accidental  Intentional(violence)  VAWC Patient  Intentional(self-inflicted)  Undetermined
First Aid Given:  Yes, What: _____________________ By whom:_______________________  No
Nature of Injury/ies: Multiple injuries?  Yes  No
(Check all applicable, indicate in the blank space opposite each type of injury the body location (site) affected and_other details)
 Abrasion _____________________________________________________________________________________
 Avulsion _____________________________________________________________________________________
 Burn [Degree ___ 1st ___ 2nd __ 3rd___ 4th ] Site: _____________________________________________________
 Concussion/TBI _______________________________________________________________________________
 Contusion ____________________________________________________________________________________
 Fracture:  Closed type: _________________________________________________________________________
 Open type :________________________________________________________________________
 Open wound. (ex. hacking, gunshot, stabbing, animal (dog, cat, rat, snake, etc) bites, human bites, insect bites, punctured
wound laceration, etc): ___________________________________________________________________
 Traumatic Amputation:__________________________________________________________________________
 Others: Pls. specify injury and the body part/s affected: ________________________________________________
_______________________________________________________________________________________________
External Cause/s of Injury/ies:
 Bites/stings, Specify animal/insect: __________________  Gunshot, specify weapon: ____________________
 Chemical/substance, specify: ______________________  Hanging/Strangulation
 Contact with sharp objects, specify object: ___________________________________________________________
 Drowning: Type/Body of Water:  Sea  River  Lake  Pool  Bath Tub  Others, specify: ________________
 Exposure to forces of nature: ______________________  Sexual Assault/ Sexual Abuse/ Rape (Alleged)
 Fall: __________________________________________  Mauling/Assault
 Firecracker, specify type/s: _____________________________________________________________________
 Burns:  Heat  Fire  Electricity  Oil  Friction  Others, specify: _____________________________________
 Transport /Vehicular Accident:  Land  Water  Air ;  collision  non-collision
Patient’s Vehicle:  None (Pedestrian)  Car  Van  Bus  motorcycle  Bicycle  Tricycle  Jeepney  Truck
 Others, ____________________ Unknown.
Other Vehicle / Object Involved (for COLLISION accident only):  None  Car  Van  Bus  motorcycle  Bicycle 
Tricycle  Jeepney  Truck  Others, ____________________  Unknown.
Position of Patient:  Pedestrian  driver/captain/pilot  Front passenger  Rear passenger  Others,___  Unknown
Place of Occurrence:  Home  school  Road  Videoke Bars  workplace, specify:_______________________
 Others, specify: _______________________________  Unknown
 Others, specify: _______________________________________________________________________________
Activity of the Patient at the time of the Other risk factors at the time of the Safety: (check all that apply)
incident:  Sports  Leisure  Work incident: (check all that apply) None  Airbag  Helmet  Seatbelt
related  Alcohol/liquor  Sleepy  Child seat  Unknown
 Others, ___________________  Using mobile phone  Life jacket/ Floatation device
 Unknown  Smoking  Unknown  Others, specify ____________
 Others, specify ____
Referred from another facility/physician  Yes, Name: _______________________________________________  No
Status upon arrival: Dead on Arrival Alive: If alive, please check if: Conscious Unconscious
Mode of transport: Ambulance Police vehicle Private vehicle Others, specify: ______
GCS BP: HR: RR: T: O2 Sat: Height Weight

Primary Survey: Time BP HR spO2

Catastrophic Hemorrhage  Yes  No
Airway: Patent Not Patent, specify: ____________________
Breathing: Breath sounds: ___________ Heart Tones: __________
crepitus: _______ chest wall tenderness: _______ others: __________
Circulation: CRT: _______, Pallor, Peripheral Pulse : ______________________
Disability: Deficits: ___________________________________________________
Exposure / Environment: _________________________________________________

Past Medical History: Medication: Allergies : No Known Allergies

HTN DM Heart Disease Asthma / COPD Food: ___________________
Cancer Others: ________________ Drugs: __________________
Diagnosis:

Diagnostics: Treatment:
Radiology Venoclysis:
Chest: APL, PA, Lat Pelvis PLR: __________________________
Cervical: AP, L, Open Mouth FAST PNSS: _______________________
Cranial CT scan WA CT Scan Medications:
Others, specify: ______________ pain: ____________________________
Laboratory Tranexamic Acid
CBC with APC BT Rh ATS / TT :_______________________
HbSAg Pt, PTT, INR Procedures:
ABGs Others, specify: ________ chest tube intubation pelvic binder
Others: posterior mold wound suturing
others: _________________________________
Blood Transfusion: ______________________________
Nurses Notes: Date and Time of Disposition
____ / ____ / _____ ; ______ hr
mm dd yyyy
Condition on Discharge:
Stable Unstable
Vital signs on Discharge:
BP: ____________________
HR: ____________________
RR: ____________________
O2 Sat: _________________

Disposition
Admitted Treated and Sent Home Transferred to another facility/hospital, specify: ______________________
HAMA Absconded Refused Admission Died
Attending Physician: __________________________________