Roche

TROP T
Troponin T
.MeMuR)a,
NARAYANI
(A Unit of Narayav I.aa.
Behala Manton, 85. (Mail - 601), Diamond Hartbour Road, Kolkata - 34 CERTIFIED
MC3625
Ph: 033-6640-0000 Website : www.narayanmemorialhospital.com
MoLKA

EMERGENCY INITIAL ASSESSMENT FORM

Patient Label: Triage Priority Red LJYellow JGreen

Patient Name:ovn ibi Age: 5 Sex

UHID:24 12)84 Er. No. 2Y DD287 Er. Bed No.:
MLC No. : Date of Arrial : 20P04
Mode of Arrival hsdhon .Atending Doctor: .xisha.ia30
Time of Arrival: .Triage Time: ..8..30MM.
Previous Admissions: Yes Date of Last Admission :

Assessment Initiation Time: Pain Score : 4|20

Chief Complaints:
3

History of Present Illness :

Results of Previous Investigation &Review of Systems :

PRIMARY SURVEY
Airway : Breathing: Circulation:
BPatent RR DPulse ..... min
OProtected
OMaintained
DLabored /Dyspnea
... mm
tA0...M
OPoripherai Hg
Pylse Kal pek.
LNormal OTemp...A8 FIC
OCompromised Spo,..H % on RA/ Rhythm ...
Disability:
GCS :
CBG
Pupil :
Right Left Rectne
Planter Right Left
General
Pallor
*,..
Jaundice Cyanosis Oedema
NMH/COPIFM/ERIni Ass/Ver.2/0424 Page 1 of 4
 SECONDARY SURVEY
ALLERGIES:

MEDIÇATÊON :

PAST HISTORY, MEDICAL,/ SURGICAL:

AMPLE
GYNAECOLOGICAL/ OBSTETRIC HISTORY:
FAMILY HISTORY:
OLMP opawÖParalGravida
PERSONAL HISTORY

LAST MEAL:

EVENTS PRIOR TO THE AILMENT / INCIDENT: WA

HEAD, EYES, EARS, NOSE, THROAT (HEENT): ui
SYSTEMIC
CHEST: NECK &L. NODES:

CVS & MURMUR: ABD :

|s, &S,:
NEURO: w EXT:

INVESTIGATION

ECG
JABG
LABORATORY:
Roche No, 2

RADIOLOGY: TROP T
TroponinT Patient:

CARDIOLOGY: Tpptia Result

Date:

Wpos Start time:

OTHERS :
neg: O
Examined by:

PROCEDURE PERFORMED IN EMERGENCY

Name of Procedure Performed By Notes

Page2 o

NMH/COP/FM/ER_Ini Ass/Ver.2/0324
 MEDICATION CHART
Administered by Time
Route
Advised by Time
Name of Drug Dose

32

Provisional
Diagnosis

DedrativeBagnosticPreventive Rehabilitative OPalliative

Goal

Plan of CareMedical Surgical

Preventive measures (if any)

Ward
CHDU
Shifted to /
Outcomne
ODischarged to Home JLAMA to OExpiry

Date &Time of Patient's Transfer Discharge / Death :

Admitted Physician's Name &Sign : Date & Time:

Secondary Physician'sName &Sign: Date & Time :

Emergency Physician's Name &Sign with Reg. No. : VisHAMALLICY

Date &Time: 2
g e n cMedicaaicer
y

Reg)HN
- 23159
Patient's I NOK's Name &Sign with Rglatidn : NARAYAN
Date & Time MEMQRJAL
HOSPITA;

NMH/COPIFM/ER Ini Ass/Ver.2/0324

OSpo
Page 3lof 4

2 o f4
 NARAYAN MEMORIAL HOSPITAL
(A Unit of Narayan Health Services Pvt. Ltd.)
Behala Manton, 85,(Mail -601), Diamond Harbour Road, Kolkata -34 CERTIFIFD
MC3623
Ph:033-6640-0000 Website : www.narayanmemorialhospital.com

Name
PARVERN D1i Age Sex: M(F)
412181 Bed No.
UHID No. IPIOP No.

Consultant: Dr. B l Kalha Diagnosis :SAWMt

CATHETERIZATION CHECKLIST Date.4044
PRE-CATHETERIZATION CHECK LIST TICK BOX FOR YES & CROSS FOR NO.
X-Ray Drug Chart Pre-mediation
Patient's Not Consent ldentityband
Serum Creatinine
PTT ECG Echo S
Blood Group Hb
Blood Serology: HbsAg HCV HIV

Others, if any
NPO Since
Pulse 9.A..
Allergies ..Ne.NCA..
Blood Pressure : ..1.SQ.. Chest with axial -
Shave:Femoral - Brachlal - Whole Body -
TIME GIVEN GIVEN BY CHECKED BY
PRE-CATHETER DRUGS PRESCRIBER'S SIGNATURE

Surgery, relevant medication) :

Other information (e.g. diabetic, Post - M.I., P.T. :if onWarfarin, Previous Cardiac

Signatur .KAaYA
POST -CATHETERIZATION CHECK LIST
Procedure: CAgPTCA.
Approach :Femoral Brachial Redia Rt Subclavian

Contrast Injections : LV Anglogram RVAngiogram

Right Coronary Arteriogram Pulmonary Artery
Left Coronary Arteriogram Right Artery
Aortogram
Route Time Sig. of Dr. Given by Cross Checked by
Name of Drugs Dosage,
3:45t
350 PM
3'55 PM
4:00PM
|4,05 PM

Circulating Nurse
".Meg.khatum
 Event Time
Act (Sec.)
Act (Sec.)

Date Nurses Assessment / Diagnosis Intervention Remarks /

1.’ Psychological Support &Reassurance Evaluation
1 Anxiety 1

given to Patient
+Put on Music System

2. P.P. of Bleeding &Haematoma 2.> Sheath in Situ 2

6FVen. Artey

7F
8F tots
+ Injection Haparin givèn
’Canulisation done by Medieingv
Single Prick
Multi Prick
Double Prick DI
3. P.P. of Haemo-dynamically unstable 3.’ Continuous Cardiac Monitoring Done 3.
doe
’ Crash Trolly ready with Defibrillator

P.P. of Neurological deflicit 4. -’Orientation Yes No 4 s Oder

+Pupil Movement
+Limb Movement
Yes
Yes
NoD
No
pe
5 P.P. of dye &date allergy 5.> Anti-allery drug given
’ Continuous monitoring of Drug Reactions as
6 P.P. of other procedural / complication 6. Yes NO 6
6A. If yes, please specify 6A. 6A.

Pt. of table ...... 393 AM/ PM ) Pt. of table ...........O) .AM PM

B.P. at start 39lgo. mm / Hg. B.P. at end. .
mm/ Hg.
HR at start
O...hmin. HR at end
I min.
Comments / Problems
SITE -Canula Insite Rt.
Lt. e tPTeAdonethaough
PULSE (Pedial)
Canula Removed
opppeh
Present
Absent
Rinht aadal sheath
Weak
Temperature of affected Limb Warm
Cool
eebmged
Follow p epplied
cdiee.
Cold
Hanu Over by
Recelved by
Saidul
Spectacles Denture X-Ray CDO Old Records