Demographics
Patient Name –
Patient DOB –
MRN –
Diagnoses
Diagnoses (list all known injuries) –
Mechanism of injury –
Background Hx –
Medical/Surgical status/Clearance for Transfer –
Medication –
Drug Allergies –
Indicate if patient has a history of Multidrug Resistant Organisms (MDROs) or other Infection Risks: (e.g. MRSA/ESBL/Clostridium Difficile/CRE/MDR Pseurdomonas)
Current Status
ACLS:
Airway -
Breathing -
Circulation -
Disability -
Enviornment -
GCS -
Injury Severity Score -
Treatment Received -
Blood Results
FBC:
HB –
RCC –
HCT –
MCV –
MCH –
MCHC –
RDW –
PLT –
WCC -
LFT:
Total Protein –
Albumin –
Total Bilirubin –
ALT –
Alkaline Phosphatase –
Gamma GT -
U&E:
Sodium –
Potassium –
Creatinine –
Urea -
CRP -
Glucose -
Coag Screen -
Lactate -
LDH -
SPEP -
Urological Injuries
Suspected urological injury (i.e. blood at urethral meatus, high riding prostate, perineal bruising, etc.) -
Details of catheter inserted (size, difficulty of insertion, haematuria) -
Urine dipstick (positive/negative for haematuria) -
Urological imaging (cystography, urethrography, CT) -
Transfer Stability Status
ICU/Ward/Not Suitable –
Referring Details
Name of Referring Hospital –
Referring Consultant –
Referring Consultant MCRN –
Name, MCRN of Referring Registrar –
Telephone Number of Referring Registrar –
