Shock Trauma Information:

STC DOE #: (ex. 145xxx)

Date/Time of STC Admission: (ex. 7/27/07 1500)

TRU Bay #: Please select... 1 2 3 4 5 6 7 8 9 11 12 13 Other

PDA Patient ID #: (ex.0015 - found on PDA under Pat. ID on the left)

Check a single box in each column representing the patient's values during your care:

Do you believe that this patient has intra-abdominal injury requiring surgery?

Please select... 1 - Highly Unlikely 2 - Unlikely 3 - Likely or Unlikely 4 - Probable 5 - Highly Probable

Event Markers Used:

Total Pre-Hospital Fluids: Crystalloids: ml Colloids: ml
Rapid Fluid Bolus ml
Drug Given - - - Specify:
BVM assisted ventilation
Intubation
CPR
Other - - - Specify:

Comments:

***Please be sure all information is correct before submitting, if you think you made a mistake after submitting please resubmit and leave a note in the comments field. Thanks!

Your Contact Info (Optional) :

Name:

Email:

Phone:

Questions about this form? (non-technical) - contact:
Chris Handley
Cell: 410-948-3984
Pager: 410-473-0333
chandley@som.umaryland.edu

For VSDR Technician Use Only:

TRU Whiteboard Info:

Initial Call Time: ETA: ^ v

Updated Call Time: ETA:

Mech. of Injury: Age/Gender:

VS:
BP: / HR: RR: SpO2:

IV: Select... Yes No Airway: MAST: Select... Yes No

Neuro - Conscious: Select... Yes No Semi

Priority: Select... Priority 1 Priority 2 Priority 3 Priority 4

Additional Info:

Estimated Vital Signs Call In Time (if update call time is not written)

Quick Form Provided? Select... Yes No

PDA Serviced? Select... Yes No