Brought In
Stretcher
Wheel-Chair
Walking
Trauma
Yes
No
Brought By
:
Relationship
:
Phone Number
:
Mode of Arrival :
Select..
Self
Referral
Triage Time
:
Triaged By
HA
Nurse
ER Course:
ER Course Description
:
Disposition :
Admitted
Discharge Home
Referral
LAMA
Death
Eloped
Instructions
Follow Up
:
Days
Weeks
Months
Remarks
: