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Emergency Room Assessment Form: Best Eye Opening Best Verbal

The emergency room assessment form summarizes a patient's vital signs, medical history, physical exam findings, and initial emergency care. It includes the patient's name, age, hospital number and mode of arrival. Sections document allergies, Glasgow Coma Scale, pain assessment, integumentary system, airway, breathing, lung sounds, oxygen therapy, IV therapy, OB/GYN history for women, medical management, and nursing interventions. The form is used to guide initial emergency care and transfer important medical information about the patient's condition.

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eliza marie luis
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694 views2 pages

Emergency Room Assessment Form: Best Eye Opening Best Verbal

The emergency room assessment form summarizes a patient's vital signs, medical history, physical exam findings, and initial emergency care. It includes the patient's name, age, hospital number and mode of arrival. Sections document allergies, Glasgow Coma Scale, pain assessment, integumentary system, airway, breathing, lung sounds, oxygen therapy, IV therapy, OB/GYN history for women, medical management, and nursing interventions. The form is used to guide initial emergency care and transfer important medical information about the patient's condition.

Uploaded by

eliza marie luis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EMERGENCY ROOM ASSESSMENT FORM

Name:________________________________________________ Age & Gender:____________


Ward/Room:___________________________________________ Hospital Number:___________
Date:________ Time:_________ Mode of Arrival:____________ Triage Category:__________________
ALLERGIES: ___________________________________

Glasgow Coma Scale


Best Eye (4) - Spontaneous (2) - To pain
Opening (3) - To voice (1) – None

Best (5)- Oriented (Coos, babbles) (2)- Incompatible Sounds


Verbal (4)- Confused (Cries) (1)- None
(3)- Inappropriate Words
(Scream/grunts)

Pain Scale ( 0 1 2 3 4 5 6 7 8 9 10 )
Location:_________________________
Quality:__________________________
Radiating at:______________________
Duration:________________________
How the pain started?:______________________

Integumentary
( ) Warm to touch ( ) Cold, Clammy
( ) Cyanotic ( ) Diaphoretic
( ) Pale ( ) Dry
( ) Jaundice ( ) Others:_______________

Airway
( ) Patent Airway
( ) Impaired Airway

Breathing
( ) Normal ( ) Deep
( ) Labored ( ) Nasal Flaring
( ) Shallow ( ) Chest Retractions
Others:_____________________________________

Lung Sounds Oxygen Theraphy


RL LL Method: ____________________________
__ Clear __ Liters/minute:________________________
__ Wheezes __ Time Started:_________________________
__ Stridor __ ET size:______________________________
__ Diminished __ Level:_______________________________
__ Pleural Rub __
__ Crackles __
Intravenous Therapy
Main Line
IVF:_________________________
Medicine Added:______________
Flow Rate:___________________
Date:_______________________

Side Drip/s
IVF:________________________ IVF:________________________
Medicine Added:_____________ Medicine Added:_____________
Flow Rate:___________________ Flow Rate:___________________
Date:_______________________ Date:_______________________

OB/GYN Medical Management


( ) Active Labor ( ) Suturing
LMP:_________________ ( ) Cast Application
EDC:_________________ ( ) CTT
FHT:_________________ FH:______________ ( ) Paracentesis
IE:___________________ ( ) Others:____________________
Gravida:_________ Para:___________
AOG:________________
Bag of Water:___________
Discharge:______________

Nursing Interventions
( ) Warm Compress ( ) TSB
( ) Cold Compress ( ) Irrigation
( ) Dressing Applied ( ) Positioning:______________________________
( ) Splint Applied ( ) Others:_________________________________
( ) Wound Cleaning

Other ASSESSMENT/S:
_____________________________________________________________________________________
_____________________________________________________________________________________

Other CONTRAPTIONS/NURSING INTERVENTIONS:


_____________________________________________________________________________________
_____________________________________________________________________________________

Test VS before transfer: BP:______ PR:______ RR:_______ T:_______ Pain Scale:________

Completed by:_______________________________

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