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] 
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] 
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] 
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] 
  • All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent.