Orthopaedics

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 -

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 –