T1	[T1Tick]
T2	[T2Tick]
T3	[T3Tick]
T4	[T4Tick]
T5	[T5Tick]

Patient Name	[PatientName]
File Number	[PatientID]
Nationality	[Nationality]
DOB	[DOB] / [Age]
Sex	[Sex]
Insurance Provider	[InsuranceProvider]

EMERGENCY NURSING ASSESSMENT

Date : [DoVisit]

PART I : NURSES ASSESSMENT

Arrival Time

[ArrivalTime]

Triage Time

[TriageTime]

Registration Time

[RegTime]

Location

[Location]

ALLERGIES:
[Allergies]

Wt. [Weight] Kg NA Ht [Height] cm NA

Birth Wt. [BWeight] gm. Length. [BLength] cm (for babies less than 1 yr)

Mode of Arrival

Ambulance

Stretcher

Wheelchair

Ambulatory

Others

[ModeOfArrivalOthers]

File Requested

Yes No

Chief Complaint:

[ChiefComplaints]

PAIN ASSESSMENT: Patient Expresses / Exhibits the presence of pain: No Yes

Character Codes = Document Term Best Describing Pain :

1. Sharp	2. Dull	3. Stabbing	4. Burning	5. Crushing
6. Deep	7. Sore	8. Aching	9. Colic	10. Throbbing
11. Numb	12. Shooting	13. Tight	14. Pulling	15. Squeezing
16. Pressing	17.Tingling	18. Colicky	19. Dragging	20. Electrifying
21. Radiating

IF PAIN INDENTIFIED, PLEASE COMPLETE BELOW:
Pain intensity : [PainIntensity] Location : [PainLocation] Frequency : [PainFrequency] Duration : [PainDuration] Radiation : [Radiation]

[tablecontent]

Past Medical History

Nil known

Diabetes

Asthma

HTN

Heart Disease

Sickle Cell

G6PD

Previous Surgery : [PastSurgicalHistory]

Others : [PastMedHistOthers]

Last Tetanus: Yes , date : [RespDate], No Unknown

Medication Nil Yes : Please list

[Medications]

Normal Stridor Dyspnea Other ________

Respiration

Normal

Laboured

Dyspnea

Other : [RespirationOthers]

Neurological

Alert Responds to voice Unresponsive GCS: [GCSValue] /15 NA
Changes noted in : Vision Hearing Speaking Ambulation Other

Psychological

Communicating well Irritable Aggressive Crying Other

Functional

Changes in Functional Status No Yes, Specify [FunctionalChanges]

Nutritional

Changes in Nutritional Status No Yes, Specify [NutritionalFunctionalChanges]

Education

No Needs Indentified Patient and Family Education Record from completed

LMP

Date : [LMPDate] [PregnantWeeks] Wks Pregnant

Other

[tableprocedure]

Others

[ProceduresOthers]

Nurses Notes

[NursesNotes]


Printed Date :	[PrintDate]		Signature & Stamp Dr. [DoctorName] [DocQualification] , [Speciality]