Trauma Admit Note

Tier level: _
 Time of Activation: _
 Time of Patient Arrival: _
 Time of Surgeon Arrival: _
 Admitting Trauma Surgeon: _
 ED physician involved and time of arrival: _
 Other physicians involved and time of arrival: _
 CT technician time of arrival: _
 Anesthesiologist time of arrival: _
 
 Age: _
 Mechanism of Injury/Findings at scene: _
 Procedures performed in field: _
 Transportation type: _
 Last meal: _
 
 Primary Survey
 Airway: [intact]
 Breathing: [normal, breath sounds equal bilaterally]
 Circulation: [skin warm, distal pulses 2+, capillary refill less than 2 seconds globally]
 Disability
 Pupils: [equal and reactive to light, _-_mm, brisk]
 GCS: [15, E=_ V=_ M=_]
 Motor Function: [move all extremities]
 Sensory: [no deficits]
 Exposure: _
 
 Secondary Survey
 VS: _
 GEN: [well developed and well nourished]
 HEAD: [NCAT]
 EYES: [pupils round reactive to light, conjunctiva clear, extraocular movements intact, no raccoons eyes]
 ENT: [no fluid in external acoustic canals, no hemotympanum, no battle's sign, nares patent, oropharynx clear]
 NECK: [no JVD, midline trachea, no cervical spine tenderness, C-collar in place]
 HEART: [regular rate and rhythm]
 LUNGS: [CTAB]
 CHEST: [chest wall non-tender, no bruising/deformity]
 ABD: [no Grey-Turner's or Cullen's sign, soft, non tender, no rebound or guarding, E-FAST scan negative at _ ]
 PELVIS: [stable to rock]
 BACK: [no step offs or deformities, T-L spine non tender]
 GU: [no perineal hematoma, NO BLOOD AT MEATUS]
 EXT: [2+ global pulses, moving all extremities well, +5/5 muscle strength globally]
 NEURO: [CNII-XII grossly intact, no sensory deficits]
 RECTAL: [good tone, no gross blood, NO HIGH RIDING PROSTATE]