Bleeding Control Assessment
Please complete this form to document and assess a bleeding control incident.
Patient Name
*
First Name
Last Name
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location/Site of Bleeding
*
Please Select
Arm
Leg
Head/Neck
Torso/Chest
Abdomen
Other
Severity of Bleeding
*
Mild (oozing)
Moderate (steady bleeding)
Severe (spurting/large volume)
Interventions Used
*
Direct pressure
Pressure dressing
Tourniquet
Hemostatic agent
Elevation
Other
Outcome/Status After Intervention
*
Bleeding controlled
Bleeding reduced but not stopped
No change in bleeding
Additional Notes or Recommendations
Submit Assessment
Should be Empty: