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BCMCH-ED-FORM 005 TRIAGE ASSESSMENT
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Date of Data collection
MM
/
DD
/
YYYY
*
Area: *
UHID: *
MODE OF ARRIVAL *
Required
DEMOGRAPHIC DETAILS: *
Yes
No
Partial
Name of the Patient
Age
Gender
Date and Time of Arrival
UHID
Greets the Patient and Relatives in Ambulance Bay while receiving *
The staff Introduces self to the patient and Relatives *
1. AIRWAY  *
RESUS
P1
P2
P3
Pediatric
ISO P1
ISO P2
OBG /GYN
NA
Maintained,
Maintained, secretion present,
Maintained, copious Secretion,
Obstructed,
2.  BREATHING *
RESUS
P1
P2
P3
Pediatric
ISO P1
ISO P2
OBG/GYN Bay
NA
Normal
Abnormal below (RR)12 and above 30
Abnormal below (RR)10 and above 35
Not Breathing
3.  CIRCULATION,  *
RESUS
P1
P2
P3
Pediatric
ISO P1
ISO P2
OBG/GYN
NA
Normal HR
Stable Patient with abnormal HR above 120 b/m
Unstable Patient with abnormal HR below 60 and above 150 b/m
Heart Rate Absent
4. MENTAL STATUS / LEVEL OF CONSCIOUSNESS
*
Yes
No
NA
Alert
To Voice
Painful Stimuli
Unresponsive / Unconscious
5. CATEGORY / SPECIAL GROUP *
RESUS
P1
P2
P3
Pedia
Iso P1/P2
OBG
NA
Abdominal Pain
Chest pain / Unstable Angina/ STEMI/ NSTEMI
Obstretics
Acute abdomen
Febrile Seizure
OPP /Drug over dose/ unknown bite/Anaphylaxis
Unresponsive
Absence of Carotid Pulse
Poly Trauma
Uncontrolled Active Seizure
Vulnerable
Urinary Retention
Seizure
Encephalitis
Meningitis
Sepsis
MODS
BURNS
RTA
Head Injury
Vomiting
Loose stool
Fever , Headache and Bodyache
CVA
Giddiness
6. APPROPRIATE COLOUR BAND APPLIED ON THE WRIST AS PER PRIORITY *
Blue
Red
Yellow
Green
NA
Resus Bay Patient
P 1 Patient
P 2 Patient
P 3 Patient
7. ALLERGIES *
Yes
No
NA
Medicine allergy documented
Food / Nuts allergy documented
Others
8. EARLY WARNING SCORE *
Yes
No
Partial
Checks Temperature,
Checks Pulse
Checks Respiration
Checks Blood Pressure
Checks Saturation
Level of conciousness
9. EARLY WARNING SCORE (TOTAL EWS SCORE) *
10. Pain assessment tool used *
Yes
No
NA
Verbal Numerical pain scale
Non verbal pain scale
Wong Baker faces pain descriptive scale
FLACC scale
NIPS & Cries
11. Pain assessment score *
12. NEUROLOGICAL ASSESSMENT USING GCS 
 Eye Opening
*
4
3
2
1
NA
Spontaneous
Speech
pain
None
13. NEUROLOGICAL ASSESSMENT USING GCS 
 -Verbal Response
*
5
4
3
2
1
NA
Oriented
Confused
Inaapropriate words
Incomprehensive sounds
None
14. NEUROLOGICAL ASSESSMENT USING GCS 
-Motor Response
*
6
5
4
3
2
1
NA
Obey commands
Localize pain
Flexible to pain
Abnormal Flexion
Abnormal Extension
None
15. TOTAL GCS SCORE  *
16. PEDIATRIC VERBAL SCORE *
5
4
3
2
1
NA
Appropriate words or social smile fixed and follows
Crying but consolable
Persistently
Restless irritable
No response
17. TOTAL PEDIATRIC VERBAL SCORE *
18.CORRECT PLACEMENT OF PATIENT AS PER PRIORITY AND EWS *
RESUS
P1
P2
P3
pedia
OBG
Iso P1/P2
NA
EWS SCORE-7 and above
EWS SCORE-5-6 any parameter 3 score
EWS SCORE -1-4
EWS SCORE- 0
19.PERFORMS SKIN ASSESSMENT USING BRADEN SCALE SKIN BUNDLE (SSKIN) *
Yes
No
NA
Assessment of Risk
Skin inspection
Surface Selection
Keep Patient Moving
Incontinence (Stool)
Incontinence (Urine)
Nutrition & Hydration
Giving Information to Patient and Relatives
20.  BRADEN SCORE *
8 - 9
10 - 12
13 - 14
15 - 18
19 - 23
NA
Very High Risk
High Risk
Moderate Risk
Preventable
Not at Risk
21.  FALL SCORE ASSESSES USING MORSE FALL SCALE *
Yes
No
NA
Fall risk assessment performed during initial assessment
Followed timely reassessment of fall risk
Yellow ID band & fall tag present for High risk patient
Staff identified vulnerable patients and provide special care for vulnerable patients
Assessment and re-assessment done as per fall risk assessment tool
Standard interventions implemented and documented for low / moderate and high risk patients
Side rails should be always raised
Use safety belts on strecther and wheel chair while transporting patient
Identify wet areas in preventing slip and trip, and takes appropriate actions
Post fall audit to be completed immediately after the incident
All staffs are trained in fall prevention and knows the hospital policy about the same
22.  FALL SCORE AND  RISK CATEGORY *
45 or higher
25 - 44
0 - 24
NA
High Risk
Moderate Risk
Low Risk
23.  PATIENT ATTENDED BY DOCTORS / NURSES
WITHIN TIME FRAME
*
Immediate
Within 5 minutes
Within in 15 minutes
Within 30 mins
More than 30 mins
NA
Resus bay Patient
P 1 patient
P 2 patient
P 3 patient
Pediatric
Obstetric Patient
24.  CONSULTATION SEEN BY PRIMARY MEDICAL TEAM *
Within 30 mins
1 hour
1 hour 30 minutes
2 hours
more than 2 hours
NA
General Medicine
Cardiology
Dermatology
Gastroenterology
Neonatology
Neurology
Obs / Gyn
Pulmonology
Pediatric
Psychiatry
Urology
ED Physician
Nephrology
25.  CONSULTATION SEEN BY PRIMARY SURGICAL TEAM *
Within 30 mins
1 hour
1 hour 30 minutes
2 hours
more than 2 hours
NA
ENT
General Surgery
Gastrosurgery
Neurosurgery
Orthopedic
Opthalmology
OFMS
Plastic Surgery
Pediatric Surgery
26. TREATMENT PLAN *
Within 30 mins
1 hour
2 hour
3 hour
4 hour
more than 4 hours
NA
Admission
Discharge
Observation
OT
LAMA
Discharge at Request
Referal
ER ICU
OPD Follow UP advised
Death
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