DEPARTMENT OF HEALTH AND FAMILY SERVICES

Division of Public Health

DPH 7483A  (10/06)

STATE OF WISCONSIN

Page 1 of 4

TRAUMA CARE FACILITY SITE REVIEW CHART SUMMARY

Facility Identifier (Date, surveyor initial, and patient number, i.e. 112606/cjd#1)

      

Demographic / Presenting Summary

AGE

       

SEX

       

MOI 

       

 

Emergency Medical System

Yes

No

Dispatch Time       

On Scene       

In Route       

GCS       

Field History EMS Run Sheet Present

RTS       

BP       

Pulse       

Resp       

Evidence of A B C Assessment

Comments:        

 

Communication to Medical Control

EMS Protocols Followed

 

Emergency Department Activation

Yes

No

Admit Date 

     

Admit Time

      

MOI meets Facility Trauma Activation

GCS      

RTS      

BP      

Pulse      

Resp      

Trauma Team Activated

Level of Activation      

Temp      

O2 Sat      

Team Response Times Appropriate

Comments:       

 

 

 

 

(Anesthesia &Trauma Surgeon Response Time is 30 Minutes for Level III Facility)

Trauma Record Completed

 

 

 

 

DPH 7483 (10/06)

TRAUMA CARE FACILITY SITE REVIEW CHART SUMMARY

Page 2 of 4

 

ED Diagnostic Evaluation

Yes

No

 

Test

Yes

No

Result

Time

 

Test

Yes

No

Result

Time

Available for MD decision making

in a timely manner?

 

H&H

     

     

 

C-Spine

     

     

Labs ordered are

 

CBC

     

     

 

Chest

     

     

X-ray completed and

 

HCT

     

     

 

Pelvis

     

     

CT completed, read and

 

T & C