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Er Triage Form

The document is a patient information form for Kebribeyah Primary Hospital, capturing essential details such as patient demographics, mode of arrival, and chief complaints. It includes sections for vital signs, triage scoring, and determining triage color based on the patient's condition. Additionally, it records any pre-hospital care and relevant medical history.

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mphamed
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439 views1 page

Er Triage Form

The document is a patient information form for Kebribeyah Primary Hospital, capturing essential details such as patient demographics, mode of arrival, and chief complaints. It includes sections for vital signs, triage scoring, and determining triage color based on the patient's condition. Additionally, it records any pre-hospital care and relevant medical history.

Uploaded by

mphamed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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KEBRIBEYAH PRIMARY HOSPITAL

1. Patient Information Age: Date of Arrival: Triage Time


Patient Name:
Sex: Time of Arrival to ED:
Card Number:
Mode of Arrival:
Origin/Home:
☐ Kebelle: , Woreda: ☐ Ambulance ☐ Public taxi
☐ Region: , Zone: ☐ Private Car ☐ Walking

Mobile No.: (Mobile no. of patient or close relative. For follow-up purposes only).

2. Was the patient referred? ☐ Gov’t Hosp. ☐ Regional Hosp. ☐ Police/prison


☐ No ☐ Yes, Indicate from: ☐ Pvt Hosp. ☐ Health Center ☐ Other:
3. Was pre-hospital care / First aid given?
☐ No ☐ Yes, Specify here:

4. Chief Complaint: ☐ Chest pain ☐ Fever ☐ Road traffic inj. ☐ Gunshot ☐ Other
☐ Respiratory sx. ☐ Headache ☐ Fall injury ☐ Stab (specify):
☐ Diarrhea/vomiting ☐ Abd. Pain ☐ Burn ☐ Swallow object
5. Duration/Date 6. Mechanism of Injury
of illness Onset: (write if self-inflicted):
7. Record Vital Signs 8 . Calculate Numerical Triage Score
HR: RR: Mobility ☐ Walking ☐ With help ☐ Stretcher/Immobile --
RR ☐ 9 - 14 ☐ 15 – 20 ☐ <9 OR 21-29 ☐ > 29
BP: T: HR ☐ 61 – 100 ☐ 41 – 60 OR 101-110 ☐ <41 OR 111-129 ☐ >129
SBP ☐ 81-100 ☐ 101 – 199 ☐ 71-80 OR >199 ☐ <71
SpO2: Temp ☐ 35-38.4 -- ☐ <35 OR >38.5 --
AVPU ☐ Alert ☐ Reacts to voice ☐ Reacts to pain ☐ Unresponsive
RBS: Trauma ☐ No ☐ Yes -- --

Triage Score: For each “þ༏”: For each “þ༏”: For each “þ༏”: For each “þ༏”:
Add 0 points Add 1 point Add 2 points Add 3 points

9. Determine Triage Color


Triage Score >7 5-6 3-4 0-2
Mechanism -- High energy transfer -- --
Presentation * Seizure (current) * Reduced consciousness * Burn (other)
* Burn * Seizure (post-ictal) * Hemorrhage (controlled)
(face/inhalation) * Acute focal neuro symptoms * Closed fx
* Hypoglycemia * Psychosis/aggression * Minor dislocation
(Glu<3) * Burn (>20%, electric, chem, circumf.) * Pregnancy + vaginal bleeding
* Hemorrhage (uncontrolled) * Pregnancy + non-abd trauma Dead on
* Pregnant + abdominal trauma / pain * DM (Gluc >17 w/o ketonuria) All other arrival
* Threatened limb OR * Abdominal pain (acute) patients
* Compound fx. * Vomiting (ongoing, no blood)
(BLACK)
* Major dislocation (not finger/toes)
* Diabetic & Glu > 11 with ketonuria
* SOB OR Chest pain (acute)
* Coughing blood OR Vomiting blood
* Poisoning / Overdose
Pain -- Severe Moderate Mild

If any present: If any present (& not red): If present (& not R / O): All others:
RED ORANGE YELLOW GREEN

10. Other History Allergies: Past medical illness(es):

Triage Officer: Signature:

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