General Practitioner-Vorlage
Strangulation Assessment
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
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Need a comprehensive Strangulation Assessment template? This template is designed for healthcare professionals, including GPs, to document incidents of non-fatal strangulation. It covers presenting complaints, detailed histories, physical examinations, investigations, assessments, and plans. This template helps clinicians to accurately record patient information, assess the severity of the incident, and create a plan for ongoing care. This template is designed to be used with Heidi, the AI medical scribe, to make documentation easy and efficient.
Vorlagenvorschau
🧍♀️ Presenting Complaint: The patient presents today following an incident of strangulation. She reports being strangled by her partner during an argument.
🗣️ History (Subjective):
Chief concern: "He tried to kill me."
Date/time of incident: The incident occurred on 31 October 2024 at approximately 22:00.
Location: The incident occurred at the patient's private home.
Assailant: The assailant was the patient's partner.
Mechanism of strangulation:
- Pressure type: ☐ Manual (hands) ☐ Ligature (cord, rope, clothing) ☒ Forearm/chokehold
- Duration of pressure: 30 seconds.
Consciousness:
- Loss of consciousness: ☒ Yes ☐ No ☐ Unsure
- Memory of event: ☐ Fully intact ☐ Partial ☒ Amnesic for part/all
Symptoms during/after strangulation:
- ☒ Shortness of breath / Difficulty breathing
- ☒ Voice change
- ☒ Neck pain
- ☒ Headache
- ☒ Dizziness
Other history:
- Any blows to head or body: ☐ Yes ☒ No
- Current medications: Sertraline 50mg daily.
- Past medical history: No significant past medical history.
Patient’s current concerns: The patient is fearful for her safety and is concerned about the possibility of future violence.
🩺 Examination (Objective):
General appearance: The patient appears distressed and tearful.
Vital signs:
- BP: 130/80
- HR: 90
- RR: 20
- Temp: 37.0
- SpO₂: 98%
Head and neck exam:
- ☒ Neck tenderness
- ☒ Bruising or abrasions
- ☐ Ligature mark or pattern injury
- ☐ Swelling or redness
- Voice: ☒ Hoarse ☐ Normal
- Neck range of motion: Reduced due to pain.
ENT findings:
- Petechiae in oral cavity: ☐ Yes ☒ No
- Tympanic petechiae: ☐ Yes ☒ No
- Other trauma: ☐ Yes ☒ No
Neurological exam:
- GCS: 15
- Cranial nerves: Normal.
- Motor/sensory: Normal.
- Balance/gait: Normal.
🧪 Investigations:
- ☒ CT neck with contrast ordered
- ☒ Photographs taken (with consent)
🧾 Assessment: The patient's symptoms and clinical signs are consistent with her account of non-fatal strangulation. There are no immediate red flags or signs of vascular or airway injury. Trauma-informed care was provided.
🧠 Plan:
- ☒ Radiology referral for CT neck (vascular protocol)
- ☒ Analgesia
- ☒ Medical monitoring if indicated
- ☒ Mental health support offered
- ☒ Safety plan discussed
- ☒ Referral to crisis services / police (with consent)
- ☐ Oranga Tamariki notified (if under 18 or vulnerable adult)
- ☒ Follow-up with GP
📝 Legal / Consent Notes:
- Informed consent obtained for examination and photography.
- Factual documentation completed.
- Referral pathway activated as per forensic protocol.
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