A thorough examination performed after a traumatic event did not identify any readily apparent injuries to the head, neck, or spine.
Used to document the absence of visible injuries to the head, neck, and spine following a trauma, but does not rule out less obvious or internal injuries. Further investigation may be necessary.
"Patient presented following a motor vehicle collision. Trauma evaluation reveals no obvious signs of head, neck, or spinal injury. Patient will be monitored for delayed onset of symptoms."
Following a traumatic event where injury to the head, neck, or spine is a possibility.
Common questions about using medical phrases in clinical documentation