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]