Emergency Department Triage form, Morton Plant Hospital

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Date:November 18, 1995
Pages:2


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Page 1 of the Emergency Dept. Triage/Nursing Assessment form generated when Lisa was admitted on November 18, 1995.

The information listed on the form includes the following:

BP 130/80 Pulse 101 Resp 20 Temp 99.8 Arrival Mode EMS Triage Code Non-Urgent Physical Assessment Color: Pink, Skin: Warm, Dry Mental Status Alert/Oriented Social History Single, Divorced Smoker no ETOH use (alcohol) occ Medications None Family History diabetes, (illegible notation) Cardiovascular Respiratory N/A, Normal Respirations Normal Lungs Clear (R & L) Abdomen Normal, Flat Ob Gyn N/A Skin Intact Neuro Normal Neurovascular Color: Pink

Temp: Warm

Motion: Full

Sensation: Intact

The narrative is difficult to read but appears to say "Pt involved in MVA, restrained driver minor damage, EMS relates pt removed all clothing MVA & requested"


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Page 2 of the Emergency Dept. Triage/Nursing Assessment form generated when Lisa was admitted on November 18, 1995.

The information listed on the form includes the following:

BP 138/84 P 92 R 18 T / O2 Sat /

Nursing Plan/Observations:

1850 - Pt A/Ox3, calm, answers questions [] eyes closed, opens on command [] short, monotone reply. Psych called for consult, friend relates pt is scientologist and psych consult is against religion, Dr. Lovett made aware.

1930 - Psych here for consult, scientologist liaison at bedside

2020 - Pt to be d/C to liaison for F/U care, pt signed AMA's [] [illegible]

General instruction given

AMB

Referred to: Personal MD