Emergency Medicine Specialist-Vorlage
Trauma ED Note_ES
Eine professionelle Emergency Medicine Specialist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need to quickly document a patient's presentation in the Emergency Department? This Trauma ED Note template is designed for Emergency Medicine Specialists to efficiently record critical information following a traumatic incident. It guides you through a structured assessment, from initial presentation and vital signs to immediate management and ongoing care. With Heidi, this template can be automatically populated from your patient's visit transcript, saving you valuable time and ensuring comprehensive documentation. This template helps you create detailed and accurate medical records, covering everything from the mechanism of injury (MOI) to the patient's disposition.
Vorlagenvorschau
Age: 32yo
Gender: Male
No known allergies
Known with:
No known chronic conditions
Appendectomy 10 years ago.
Smoker, 10 cigarettes per day. Drinks alcohol socially. Works as a software engineer. Lives in a flat with his partner.
Father with hypertension.
Now:
Patient presents following a road traffic accident. Complains of chest pain and difficulty breathing. Symptoms started immediately after the accident.
- DOI 01/11/2024 14:30
- MOI Road traffic accident
Chest pain is sharp, rated 8/10, worse on inspiration. Shortness of breath. No other associated symptoms.
No loss of consciousness.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
None.
EMS Handover:
Patient involved in a road traffic accident. Complains of chest pain and shortness of breath. Oxygen administered via nasal cannula at 2L/min. IV access established. No medications given.
Vitals:
BP 130/80 mmHg, HR 110 bpm, RR 24 bpm, Sats 94% RA, T 37.0°C
Primary Survey:
A: Airway patent and maintainable, no abnormal airway sounds.
C-Spine: No abnormal findings, no evidence of intoxication, no distracting injury present.
B: Breathing within normal limits, trachea central, no distress.
C: Haemodynamically stable, abdomen soft/non-tender, pelvis stable, no fractures, no active bleeding.
D: GCS 15/15, PEARLA, moving all limbs, no focal neurology.
E: Normal log-roll, no midline tenderness, no spinal deformity. Rectal exam deferred as not indicated.
Immediate Management:
- Managed according to ATLS principles, monitors applied
- A: None.
- B: Oxygen via nasal cannula at 2L/min.
- C: IV access established, fluids administered.
- D: None.
- E: Kept warm, temperature monitored and treated if required.
CXR, ECG.
None.
None.
Secondary Survey:
Head: NAD.
ENT: NAD.
Eyes: NAD.
Neck: NAD.
Clavicles: NAD.
Chest: NAD.
Abdomen: NAD.
Pelvis: NAD.
Back: NAD.
Upper limbs: Bilateral full ROM, NVI, NAD.
Lower limbs: Bilateral full ROM, NVI, NAD.
ICD-10 diagnosis codes: S22.3 Fracture of sternum, W49.0 Exposure to unspecified mechanical forces
Assessment:
?Fractured sternum
Stable
None.
None.
DOI 01/11/2024 14:30
MOI Road traffic accident
Differential:
Pneumothorax, pulmonary contusion.
Continued Management Plan:
- Managed according to ATLS principles
Analgesia for pain.
Repeat CXR, consider CT chest.
None.
None.
Discussed injury and management plan with patient.
Yes.
Discussed with the on-call general surgeon.
Review in 2 hours.
Admitted for observation.
None.
None.
Follow up with fracture clinic in 6 weeks.
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