Emergency Department Triage form, Morton Plant Hospital
| Date: | November 18, 1995 |
| Pages: | 2 |
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"
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