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Emergency Medicine Physician
30-45 minutes

Secondary Survey Documentation for Trauma Assessment

The Emergency Trauma Assessment (Secondary Survey Notes) template by s10.ai is a vital resource for emergency medicine professionals, offering a structured approach to document a detailed secondary survey of trauma patients. It captures essential data, including AMPLE history, physical examination results, and the assessment and plan, ensuring comprehensive documentation of patient status, interventions, and consultations. This template enhances communication among healthcare providers and is perfect for high-stress emergency environments, streamlining the documentation process to ensure every critical detail in trauma patient care is meticulously recorded.

4,908 uses
4.5/5.0
D
Dr. Ethan Caldwell
Template Structure

Organized sections for comprehensive clinical documentation

[Patient Age] [Patient Gender, "M" for male, "F" for Female or "X" for non-binary] ["BIBA" if brought in by ambulance, or "PW" if presents via other means] [Brief summary of presentation]
Secondary Survey:
AMPLE History:
- Allergies: [List if known, write "unknown" if not known or "NKDA" if no known drug allergy]
- Medications: [Include anticoagulants, insulin, steroids, etc. if unknown write "unknown"]
- Past Medical History: [Include significant conditions, if unknown write "unknown", If none write "Nil Significant"]
- Last Meal: [Time and contents, if unknown write "unknown"]
- Events Leading to Injury: [Details from patient, family, or EMS, if unknown write "unknown"]
Physical Exam:
- Head & Face: [Scalp injuries, facial fractures, hemotympanum, septal hematoma, facial asymmetry, battle sign]
- Cervical Spine: [Tenderness, need for imaging]
- Thorax: [Rib fractures, lung auscultation, heart sounds, if heart sounds are dual no murmurs write "HSDNM"]
- Abdomen/Pelvis: [Tenderness, guarding, rebound, bruising, if the pelvis is stable/unstable and if a pelvic binder is in situ]
- Extremities: [Deformities, pulse presence, sensory/motor function, Include neurovascular status of each limb and if gross sensation is intact in each limb]
- Back: [Spinous process tenderness, step-offs, any large bruises, wounds or lacerations]
- Digital Rectal Exam: [Only if indicated before urinary catheter placement]
Assessment & Plan
- Summary of Findings [Summarize key injuries, GCS, hemodynamic status]
- Interventions Performed: [Airway management, chest tube placement, fluid resuscitation, blood products, etc.]
- Pending Procedures & Investigations: [Any procedures yet to be completed or investigations pending]
- Disposition: [ICU admission, OR, imaging, interventional radiology]
- Consultations: [List specialists consulted, e.g., trauma surgery, neurosurgery]
Sample Clinical Note

Example of completed documentation using this template

Patient Age: 34, Patient Gender: M, BIBA, Patient was involved in a high-speed motor vehicle collision.
Secondary Survey:
AMPLE History:
- Allergies: NKDA
- Medications: Unknown
- Past Medical History: Nil Significant
- Last Meal: Unknown
- Events Leading to Injury: Patient was driving when another vehicle collided with the driver's side.
Physical Exam:
- Head & Face: Laceration on the scalp, facial asymmetry noted
- Cervical Spine: Tenderness present, imaging required
- Thorax: Rib fractures on the left side, HSDNM
- Abdomen/Pelvis: Tenderness in the lower abdomen, pelvis stable
- Extremities: Deformity in the right leg, pulses present, gross sensation intact
- Back: No spinous process tenderness, large bruise on the lower back
- Digital Rectal Exam: Not indicated
Assessment & Plan
- Summary of Findings: GCS 14, hemodynamically stable, multiple rib fractures, right leg fracture
- Interventions Performed: Airway management, fluid resuscitation
- Pending Procedures & Investigations: CT scan of the cervical spine, X-ray of the right leg
- Disposition: ICU admission
- Consultations: Trauma surgery, orthopaedics
Timestamp: 1 November 2024, 14:30 - Airway management initiated  
Timestamp: 1 November 2024, 15:00 - Fluid resuscitation started
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals conducting a secondary survey in emergency settings. It includes essential components such as AMPLE history, physical examination findings, and a detailed assessment and plan section. Clinicians can efficiently record patient information, including allergies, medications, past medical history, and events leading to injury, ensuring a thorough understanding of the patient's condition. The template also facilitates the documentation of physical exam results across various body systems, aiding in the identification of critical injuries and guiding immediate interventions. With sections dedicated to summarizing findings, interventions performed, pending procedures, and consultations, this template supports accurate and timely decision-making. By adopting this template, healthcare providers can enhance patient care, improve communication among medical teams, and ensure comprehensive documentation for optimal patient outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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