Get Illness And Injury Assessment Record Sheet - Diveaai.com

Filling out the Illness And Injury Assessment Record Sheet is a crucial step in documenting patient assessments. This guide provides a clear overview of how to complete the form accurately and effectively, ensuring all necessary information is captured.

Follow the steps to successfully complete the record sheet.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. This includes the patient's full name, date of birth, and contact details, such as address and phone number. Be sure to also indicate any medical alert tags that the patient may have.
3. Assess and document the patient's condition at the beginning of care. Select whether the patient is conscious or unconscious and note their position prior to care (standing, sitting, or lying).
4. In the illness section, use the prompts to gather information regarding the patient's signs and symptoms. Document the patient’s pulse rate and describe the pulse's characteristics (rapid, strong, weak).
5. Continue collecting data by recording the patient’s respiration rate and characterizing their breathing (rapid, slow, labored). Additionally, note any complaints, such as shortness of breath or chest pain.
6. In the allergies section, ask the patient about any known allergies and whether they have ingested anything they may be allergic to. Record their responses appropriately.
7. Next, inquire about any medications the patient takes, including the type and dosage. Ensure to ask if they took their medication on that day and document the details.
8. For preexisting conditions, determine whether the patient has any medical conditions that could affect their care and note these details.
9. Gather information regarding the patient’s last meal and recent events that may have contributed to their condition. Document these responses thoroughly.
10. When filling out the injury assessment, provide a detailed history of the incident, including what happened and how the injury occurred. Describe the injury location using the provided key.
11. Summarize the emergency responder care given by documenting any actions taken and any further notes that may assist in the patient's ongoing care.
12. After completing the form, you can save your changes, download, print, or share the record sheet as needed.

Complete your documents online today for a streamlined and effective documentation process.