DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7483B (10/06)

STATE OF WISCONSIN Page 1 of 2

TRAUMA CARE FACILITY SITE REVIEW CHART SUMMARY To complete this form on computer use the TAB key to move from one section to another and click to select the Check box(es).

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

Patient Age

Male Female

Facility Admit Yes No

Mode of Arrival EMS Pvt.Car

ED Arrival Time

ED discharge Time

ED LOS

Transferred Yes No

Mechanism of Injury

Comments:

Expired Yes No

Pre-Hospital Information

EMS Run Sheet on Chart Yes No

EMS Scene > 20 min Yes No

C-collar Yes No

Extrication Yes No

Comments:

Spinal Immobilization Yes No

BP:

P:

Resp:

RTS:

GCS:

Intubation Yes No

Oxygen Yes No

Clinical Information

ED MD Notified @

Arrived @

Surgeon Notified @

Arrived @

Comments/Recommendations

Trauma Team Activated Yes No

Appropriate Yes No

Admitted to Surgical Service Yes No

Transferred Yes No

Time of Transfer:

Receiving Facility:

Mode of Transfer :

Documentation

Trauma Flow Sheet Used Yes No

Serial Vital Signs completed Yes No

Comments/Recommendations

Initial ED vital signs

BP:

Pulse:

Resp:

Temp:

GCS:

SpO2:

RTS:

Final ED vital signs

BP:

Pulse:

Resp:

Temp:

GCS:

SpO2:

RTS:

Treatments

IV’s x:

Gauge:

Amt:

Fluid:

O2 @ By:

Other Treatments/ Comments:

Blood T&C Yes No

Central Line Placed Yes No

Foley Cath Placed Yes No

Units Transfused

Chest Tube Placed Yes No

OG / NG placed Yes No

DPH 7483B (10/06)

Page 2 of 2

Diagnostics	Labs drawn @ Results↓	Plain Films To X-ray @	CT Scans To CT @	Injuries / Abnormal Findings
Comment/Recommendations	Hct / Hgb	Chest Yes No + -	Head Yes No + -
	ABG (ph)	C-spine Yes No + -	Chest Yes