Emergency Department/Urgent Care Center Triage
Patient age: 78 Birth Sex in chart: MALE
Mode of Arrival
Ambulance
Pre-arrival interventions
transfer from barstow comm ED
Mode of Mobility: *
Stretcher
Chief Complaint
afib, sob
Triage RN Note (Subjective/Objective)
pt biba, xfer from barstow comm ed for afib and sob/copd exacerbation. pt calm
quiet cooperitive, gcs 15 a/ox4, respirations even, shallow, unlabored, non
productive cough, speaking in 2-7 word senctences, 2L o2 via NC “as needed” per
pt, skin warm and dry, mucous membranes moist, no distress, ekg completed,
placed on cardiac monitor, labs drawn and sent per md orders. dr zaidi at
bedside for eval.
Level of Consciousness (AVPU)
Alert = Appears aware of and responsive to the environment on their own.
Follows commands, opens eyes spontaneously, and tracks objects.
Vital Signs
Vital signs previously recorded this visit
VSD – Detailed Vitals
Date Vital Measurement Qualifiers
06/12/2025 20: 50 Temp F (C) 97.9 (36.6)
” ” Pulse 122
” ” Respir 22
” ” BP 111/66
” ” Pain 0
” ” POx (L/Min)(%) 96 (2)() Nasal Cannula
05/22/2025 14: 44 Wt lbs (kg)[BMI] 214.9 (97.48)[30*]
07/11/2019 13: 53 Ht in (cm) 71 (180.34)
National Early Warning Score (NEWS)
The NEWS total is 6.
- Temperature (C/F):
Score = 0 36.1 – 38.0 C (96.9 – 100.4 F)
- Pulse:
Score = 2 111-130
- Respirations:
Score = 2 21-24
- Blood Pressure (Only Systolic BP, mmHg):
Score = 0 111-219
- Pulse Oximetry:
Score = 0 96% or greater
- Supplemental oxygen in use:
Score = 2 Yes
- AVPU:
Score = 0 Alert
Pain
No pain
Pain Score: 0
Suicide Screen
Columbia Suicide Severity Rating Scale (C-SSRS) screener
- Over the past month, have you wished you were dead or wished you could go
to sleep and not wake up?
No
- Over the past month, have you had any actual thoughts of killing yourself?
No
- Over the past month, have you been thinking about how you might do this?
Response not required due to responses to other questions.
- Over the past month, have you had these thoughts and had some intention of
acting on them?
Response not required due to responses to other questions.
- Over the past month, have you started to work out or worked out the
details of how to kill yourself?
Response not required due to responses to other questions.
- If yes, at any time in the past month did you intend to carry out this
plan?
Response not required due to responses to other questions.
- In your lifetime, have you ever done anything, started to do anything, or
prepared to do anything to end your life (for example, collected pills,
obtained a gun, gave away valuables, went to the roof but didn’t jump)?
No
- If YES, was this within the past 3 months?
Response not required due to responses to other questions.
Emergency Severity Index (ESI) level
Level 2
Fall Risk Screen
Patient is considered a fall risk due to the following
Age greater than 70
Interventions
Fall prevention instructions given
Patient placed in view of staff
Previously documented allergies: Patient has answered NKA
Current Problems
Atrial fibrillation (SCT 49436004)
Chronic obstructive lung disease (SCT 13
Hyperlipidemia (SCT 55822004)
Anxiety (SCT 48694002)
History of alcohol abuse (SCT 371434005)
Allergic rhinitis (SCT 61582004)
Hearing Loss (SCT 15188001)
Tinnitus (SCT 60862001)
Order SWS/EMERGENCY DEPT OUTPT Consult?
No
Reason
–
Gynecological Assessment
Is the patient homeless?
No
Are you on hospice?
NO
Dispo to: bed 19
RN