271 lines
5.9 KiB
Markdown
271 lines
5.9 KiB
Markdown
# Urgent Care Triage Assessment
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| Form ID | FRM-UC-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Date of Birth | |
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| Age | |
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| Sex | ☐ Male ☐ Female |
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| Date | |
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| Time of Arrival | |
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| Time of Triage | |
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---
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## Chief Complaint
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*In patient's own words:*
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**Duration of Symptoms:**
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---
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## Vital Signs
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| Parameter | Value | Normal? |
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|-----------|-------|---------|
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| Temperature | °F / °C | ☐ Yes ☐ No |
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| Heart Rate | bpm | ☐ Yes ☐ No |
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| Respiratory Rate | /min | ☐ Yes ☐ No |
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| Blood Pressure | / mmHg | ☐ Yes ☐ No |
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| SpO2 | % on ☐ RA ☐ O2 ___L | ☐ Yes ☐ No |
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| Pain Score | /10 | |
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| Weight | kg / lbs | |
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| Blood Glucose (if indicated) | mg/dL | ☐ N/A |
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---
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## Allergies
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☐ No Known Drug Allergies (NKDA)
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☐ No Known Allergies (NKA)
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| Allergen | Type | Reaction |
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|----------|------|----------|
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| | ☐ Drug ☐ Food ☐ Environmental | |
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| | ☐ Drug ☐ Food ☐ Environmental | |
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| | ☐ Drug ☐ Food ☐ Environmental | |
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---
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## Current Medications
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| Medication | Dose | Frequency |
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|------------|------|-----------|
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---
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## Brief Medical History
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☐ None significant
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| Condition | Yes | Condition | Yes |
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|-----------|-----|-----------|-----|
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| Diabetes | ☐ | Heart Disease | ☐ |
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| Hypertension | ☐ | Lung Disease/Asthma | ☐ |
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| Kidney Disease | ☐ | Liver Disease | ☐ |
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| Blood Clots/DVT | ☐ | Cancer | ☐ |
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| Seizures | ☐ | Immunocompromised | ☐ |
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| Pregnancy | ☐ (LMP: _______) | Other: | ☐ |
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---
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## History of Present Illness
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### OPQRST
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| Element | Response |
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|---------|----------|
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| **O**nset: When did this start? | |
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| **P**rovocation: What makes it better/worse? | |
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| **Q**uality: Describe the symptom | |
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| **R**adiation: Does it travel anywhere? | |
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| **S**everity: How bad is it (0-10)? | |
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| **T**iming: Constant or comes and goes? | |
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### Associated Symptoms
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| Symptom | Present | Symptom | Present |
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|---------|---------|---------|---------|
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| Fever/Chills | ☐ | Nausea/Vomiting | ☐ |
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| Headache | ☐ | Diarrhea | ☐ |
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| Shortness of Breath | ☐ | Urinary Symptoms | ☐ |
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| Chest Pain | ☐ | Rash | ☐ |
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| Dizziness | ☐ | Weakness | ☐ |
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| Cough | ☐ | Vision Changes | ☐ |
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| Sore Throat | ☐ | Numbness/Tingling | ☐ |
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---
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## Quick Look Assessment
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### General Appearance
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| Observation | Finding |
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|-------------|---------|
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| Alert and oriented | ☐ Yes ☐ No |
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| In acute distress | ☐ Yes ☐ No |
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| Skin color | ☐ Normal ☐ Pale ☐ Flushed ☐ Cyanotic |
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| Respiratory effort | ☐ Normal ☐ Labored |
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| Ambulation | ☐ Independent ☐ Assisted ☐ Wheelchair ☐ Stretcher |
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| Obvious injuries | ☐ None ☐ Present: _______ |
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---
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## Screening Questions
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### Safety Screens
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| Question | Response |
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|----------|----------|
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| Fall in past 24 hours? | ☐ Yes ☐ No |
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| Head injury? | ☐ Yes ☐ No |
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| Loss of consciousness? | ☐ Yes ☐ No |
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| Recent surgery? | ☐ Yes (When: _______) ☐ No |
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| Recent travel? | ☐ Yes (Where: _______) ☐ No |
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| Exposure to COVID-19/illness? | ☐ Yes ☐ No |
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### For Women of Childbearing Age
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| Question | Response |
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|----------|----------|
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| Could you be pregnant? | ☐ Yes ☐ No ☐ N/A |
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| Last menstrual period | |
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| Currently breastfeeding? | ☐ Yes ☐ No ☐ N/A |
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## Red Flag Assessment
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**Check if ANY present (requires immediate provider notification):**
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| Red Flag | Present |
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| Chest pain/pressure | ☐ |
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| Difficulty breathing at rest | ☐ |
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| SpO2 <92% | ☐ |
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| Severe headache (worst of life) | ☐ |
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| Sudden vision loss | ☐ |
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| Sudden weakness/numbness | ☐ |
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| Speech difficulty | ☐ |
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| Facial droop | ☐ |
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| Uncontrolled bleeding | ☐ |
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| Altered mental status | ☐ |
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| Syncope | ☐ |
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| Anaphylaxis symptoms | ☐ |
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| Suicidal/homicidal ideation | ☐ |
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**If ANY checked → Immediate provider evaluation and consider ED transfer**
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## Acuity Level Assigned
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☐ **Level 1 - Emergent** (ED Transfer Required)
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→ Provider/911 notified: Time _______ Name _______
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☐ **Level 2 - Urgent** (Provider within 15 min)
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→ Provider notified: Time _______
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☐ **Level 3 - Semi-Urgent** (Provider within 30 min)
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☐ **Level 4 - Non-Urgent** (Provider within 60 min)
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☐ **Level 5 - Redirect** (Outside UC scope)
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→ Redirected to: _______
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## Interventions Initiated
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| Intervention | Ordered | Completed |
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|--------------|---------|-----------|
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| Ice pack | ☐ | ☐ |
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| Elevation | ☐ | ☐ |
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| Wound care | ☐ | ☐ |
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| POC glucose | ☐ | ☐ |
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| POC UA | ☐ | ☐ |
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| POC strep | ☐ | ☐ |
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| POC flu/COVID | ☐ | ☐ |
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| ECG | ☐ | ☐ |
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| Other: | ☐ | ☐ |
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## Pain Assessment
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| Field | Entry |
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|-------|-------|
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| Location | |
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| Quality | ☐ Sharp ☐ Dull ☐ Aching ☐ Burning ☐ Throbbing |
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| Intensity (0-10) | /10 |
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| Onset | ☐ Sudden ☐ Gradual |
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| Duration | |
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| What relieves it? | |
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| What worsens it? | |
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| Previous episodes? | ☐ Yes ☐ No |
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---
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## Injury Details (if applicable)
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| Field | Entry |
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| Mechanism of Injury | |
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| Time of Injury | |
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| Location of Injury | |
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| Tetanus status | ☐ Up to date ☐ Needs update ☐ Unknown |
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| Work-related? | ☐ Yes ☐ No |
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## Additional Notes
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## Re-Triage (if waiting time extended)
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| Time | Vital Signs | Condition Changed? | New Acuity | Initials |
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| | | ☐ Yes ☐ No | | |
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| | | ☐ Yes ☐ No | | |
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| | | ☐ Yes ☐ No | | |
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## Triage Nurse/MA Signature
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| Field | Entry |
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|-------|-------|
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| Name | |
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| Credentials | |
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| Signature | |
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| Date | |
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| Time | |
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## Provider Acknowledgment
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| Field | Entry |
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| Provider notified at | (time) |
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| Provider seen at | (time) |
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| Provider Signature | |
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*Form FRM-UC-001 Rev 1.0 - Urgent Care Triage Assessment*
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