Published
Top part of sheet-Demographic Info and C/C.
Middle part of sheet- current VS and med info.(allergies and current meds) and Cultural/religous/learning or special needs.
Bottom Part of sheet-assement from Head to to toe with check offs for each assessing tool prompt, 0-10 pain scale on side of sheet in eng/and spanish
Very Bottom of sheet open lines to write any Misc Info/interventions done in triage/or changes in V/S.... Hope this helps..I like OUr sheet.
the front left half is the triage/hx/vs...right side is initial assess, objective data, on the back is the nursing documentatin for the visit with mar/iv flow/vs etc....we have about a dozen different focus sheets, MVA, respiratory, chest pain....there are check-offs r/t primary complaint, like, monitor/o2/ekg would be on the chest pain sheet. It's called a t-sheet system..we just changed....l don't care very much for it.....yet...........LR
We use a one page sheet; Top to bottom:
name, DOB, age, sex, VS,Triage code (for acuity)
allergies, Tx prior to arrival (EMS)
medical history (check off for majors-cardiac, COPD, IDDM,etc-and an additional line for not so common)
Surgical history (again check off and addditional line)
Check off boxes for chief complaint
lines for head to toe with checkoff for breath sounds, distress level, skin (WNL, pale, diaphoretic, etc), and 1-10 pain scale
nurse signature
MD signature (after exam)
It flows really well, and is easy to use and to call report from.
Triage sheet!? Oh yes, I remember the nice simple to use, flow sheets that actually told people why the pt was being seen.
Now days I have a wonderful, (well, that is what they tell us), computer program that goes through 5 screens to get the same information. Going paperless was one of the best moves we made ( according to the office supply store). Our paper use has gone up by about 8 times....go figure. It has also just about tripled the time it takes to triage a person...at least it means job security for the IS types.
bob
ernurse728, LPN
130 Posts
I am curious as to what types of setup different ER's have for there triage sheets. We are currently in the process of redesigning ours. We are a community hospital with a 40 bed ER. Any help would be greatly apppreciated. Thanks!