Trauma note

Profile: [Patient name, age, and mechanism of trauma including whether blunt or penetrating and specific mechanism such as fall, single vehicle crash, head-on motor vehicle crash, knife, or gunshot wound] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) [Level of trauma activation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Primary Survey: [EMS vitals including heart rate, blood pressure, respiratory rate, oxygen saturation, and glucose if obtained. Calculate and include shock index as heart rate divided by systolic blood pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [First set of in-hospital vitals including heart rate, blood pressure, respiratory rate, oxygen saturation, and glucose if obtained. Calculate and include shock index as heart rate divided by systolic blood pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Airway: [Airway status including whether patient is maintaining and protecting own airway, presence of blood, vomit or foreign objects in the mouth, abnormal sounds such as snoring or stridor, and any airway interventions performed prior to or on arrival in hospital] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) Breathing: [Chest examination findings, description of lung sounds, work of breathing, and all breathing interventions including oxygen delivery rate and route, needle decompression, and chest tube insertion] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) Circulation: [Visible major external bleeding, abdominal examination findings, pelvic stability, long bone fractures, capillary refill, and warmth of extremities including initial management of any identified sources of bleeding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) [Vascular access obtained] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Initial fluid resuscitation ordered, specifying whether crystalloid or saline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Disability: [Total GCS score with individual component scores for Eyes, Verbal, and Motor] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Pupil size, reactivity, and whether equal or unequal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Motor and sensation status in all four limbs, including any deficits identified] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [First glucose recorded] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Management of any suspected raised intracranial pressure or low glucose] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Whether the cervical spine was clinically cleared or not, and whether a cervical collar was applied] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Environmental and Exposure: [Patient temperature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Whether a log roll was performed and findings on the patient's back] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Whether a digital rectal exam was performed, recommended and declined, or not mentioned, and findings if performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Adjuncts: POCUS: [Point of care ultrasound findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Labs: [Laboratory results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Initial Imaging: [Chest and pelvic x-ray findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Initial Disposition: [If a transfer is planned following the primary survey, include the destination facility, method of transportation, and expected timeline. Otherwise omit this section entirely] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) AMPLE History: Allergies: [Known allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Medications: [Patient's home medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) [Date or status of last tetanus immunisation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Past Medical History: [Relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Last Meal: [Time and content of last meal] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Events Prior: [Description of events leading up to the trauma, including who provided the history such as the patient, EMS, police, or a family member] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) Secondary Survey: [Repeat set of vitals obtained after the primary survey] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) [Head to toe physical examination with all findings documented and all interventions performed in response to those findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) [Any additional imaging performed after the initial chest and pelvic x-rays] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Assessment: [Patient age, type and level of trauma, and haemodynamic stability] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) [List of patient injuries in order of severity, beginning with the most severe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a numbered list.) Treatment in Facility: [All treatments performed in the emergency department including all medications administered with dose and route, all procedures performed in detail, and all fluids given with volumes for each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) Summary of Red Call: [Summary of any conference calls regarding the patient's care] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) Plan: [Transfer plan if applicable, including destination hospital, method of transportation specifying ALS or ACP if transfer is by RISE Air or road ambulance, and receiving service such as trauma, emergency physician, or orthopaedics. If no transfer is planned, omit this section entirely] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences.) [Final vitals prior to leaving the department including calculated shock index as heart rate divided by systolic blood pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.)