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APGAR Score

Appearance (Skin Color): 0 - Blue or pale all over 1 - Body pink, extremities blue 2 - Completely pink Pulse (Heart Rate): 0 - Absent 1 - Below 100 bpm 2 - Over 100 bpm Grimace (Reflex Irritability): 0 - No response 1 - Minimal Response 2 - Prompt Response Activity (Muscle Tone): 0 - Absent 1 - Arms and legs flexed 2 - Active movement Respiration (Breathing Rate and Effort): 0 - Absent 1 - Slow or irregular breathing 2 - Good, strong cry Patient Appearance: In No Obvious Distress In Obvious Distress

Pain Onset: Gradual Sudden Provocation: Effect of Provocation: Better Worse No Change Pain Quality: Dull Sharp Throbbing Aching Stabbing Burning Cramping Pressure Radiating Pulsating Constant Intermittent Tingling Pain Radiation: None Head Neck Arm Hand Chest Leg Back Foot Pain Severity: 1 2 3 4 5 6 7 8 9 10 Pain Duration: Time Unit of Pain: Minute(s) Hour(s) Day(s) Week(s) Month(s) Year(s)

APGAR Score Reassessment

Appearance (Skin Color): 0 - Blue or pale all over 1 - Body pink, extremities blue 2 - Completely pink Pulse (Heart Rate): 0 - Absent 1 - Below 100 bpm 2 - Over 100 bpm Grimace (Reflex Irritability): 0 - No response 1 - Minimal Response 2 - Prompt Response Activity (Muscle Tone): 0 - Absent 1 - Arms and legs flexed 2 - Active movement Respiration (Breathing Rate and Effort): 0 - Absent 1 - Slow or irregular breathing 2 - Good, strong cry

Transport Destination: Baptist Health Hamburg Baptist Health Lexington Baptist Health Richmond Berea Health and Rehab Berea Terrace Casey County Hospital Ephraim McDowell James B Haggin Ephraim Mcdowell Fort Logan Kenwood Health and Rehab Landmark of Lancaster Madison Health and Rehab Other Rockcastle Regional Saint Joseph Berea Saint Joseph Jessamine Saint Joseph Main University of Kentucky Movement Method: Self Ambulation Assisted Ambulation Stair Chair Backboard Scoop Stretcher Draw Sheet Method Carried Movement Destination: Stretcher Captain's Chair Bench Seat Transport Status: Emergent Non-Emergent Transport Lights: With Lights and Sirens Without Lights and Sirens Destination: Hospital Bed Bed Wheelchair Couch Chair Operating Room Table Cath Lab Table Exam Table Transfer Method: Self Ambulation Assisted Ambulation Stretcher Stair Chair Backboard Scoop Stretcher Draw Sheet Method Carried Transfer of Care to: Nursing Staff Patient Power of Attorney Legal Guardian

Who is Refusing: None Patient Power of Attorney Legal Guardian Notice of Privacy Practices was left with: Patient Power of Attorney Legal Guardian They denied a copy

Exceptions: