Trauma ED Note_ES

[Age] (If adult patient, write the age in years with yo after the number. If paediatric patient, write in years and/or months depending on transcript, using yo and mon. Example: 2yo 5mon.) [Gender] (Indicate male or female.) [List any allergies to medications, latex, food or other substances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. If noted as no allergies, write "No known allergies". If not mentioned, omit completely.) [Pregnancy and obstetrics details] (Only include if explicitly mentioned. Use GxPxMxEx with gestational age and booking details where available. If not mentioned, omit completely.) Known with: [List any known chronic conditions] (Only include if explicitly mentioned; otherwise, write "No known chronic conditions".) [Detail past medical history not included under chronic conditions, including resolved conditions, previous surgeries] (Only include if explicitly mentioned; otherwise omit completely.) Chronic meds: [List chronic medication taken for known chronic conditions, including dosage and frequency where possible] (Only include if explicitly mentioned; otherwise omit completely.) [Detail social history including smoking, alcohol, drug use, work/study, living situation, living conditions, social services, activities of daily living] (Only include if explicitly mentioned; otherwise omit completely.) [Detail any relevant family history of medical conditions, including age of onset, severity, and family members affected] (Only include if explicitly mentioned; otherwise omit completely.) (Only include the following if paediatric patient <13yo.) [RVD status] (Only include if explicitly mentioned; otherwise omit completely.) [Immunisation status] (Only include if explicitly mentioned; otherwise omit completely.) [Birth history details] (Only include if explicitly mentioned; otherwise omit completely.) [Growth status and details] (Only include if explicitly mentioned; otherwise omit completely.) Now: [Description of reason for emergency visit, including duration of symptoms if mentioned] (Only include if explicitly mentioned; otherwise omit completely.) - DOI [Date and time of injury] (Only include if explicitly mentioned; otherwise omit completely.) - MOI [Mechanism of injury] (Only include if explicitly mentioned; otherwise omit completely.) [Detail history of presenting illness including onset, duration, severity, associated symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail any negative symptoms to support diagnosis] (Only include if explicitly mentioned; otherwise omit completely.) [Detail current medication taken for presenting illness, including dosage, frequency, and timing if available] (Only include if explicitly mentioned; otherwise omit completely.) [Detail constitutional symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail eye-related symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail ENT symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail cardiovascular symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail respiratory symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail gastrointestinal symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail genitourinary symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail gynaecological/obstetric symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail musculoskeletal symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail dermatological symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail neurological symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail psychiatric symptoms, include quotations if explicitly mentioned] (Only include if explicitly mentioned; otherwise omit completely.) [Detail endocrine symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail haematologic/lymphatic/oncology symptoms] (Only include if explicitly mentioned; otherwise omit completely.) [Detail allergic/immunologic symptoms] (Only include if explicitly mentioned; otherwise omit completely.) EMS Handover: [Details of EMS handover including accident details, findings, treatment, medications given with doses/times] (Only include if explicitly mentioned; otherwise omit completely.) Vitals: BP [Blood pressure mmHg], HR [Heart rate bpm], RR [Respiratory rate bpm], Sats [Oxygen saturation %, specify RA or FiO2%], T [Temperature °C] Weight [Weight in kg] (Always include for paediatric patients if mentioned; omit for adults if not mentioned.) [Hb] (Only include if explicitly mentioned; otherwise omit completely.) [Hgt] (Only include if explicitly mentioned; otherwise omit completely. Write Hgt, not HCT.) [Udip] (Only include if explicitly mentioned; otherwise omit completely.) [Urine prognostic] (Only include if explicitly mentioned; otherwise omit completely.) Primary Survey: A: [Airway findings, include patency, sounds, airway trauma, adjuncts used] (Only include if explicitly mentioned; otherwise state "Airway patent and maintainable, no abnormal airway sounds.") C-Spine: [Cervical spine findings including inspection, deformity, tenderness] (If not mentioned, state "No abnormal findings, no evidence of intoxication, no distracting injury present.") B: [Breathing/respiratory findings including trachea, GAEB, signs of distress, oxygen given] (If not mentioned, state "Breathing within normal limits, trachea central, no distress.") C: [Cardiovascular findings including haemodynamic status, abdomen/pelvis, fractures, bleeding] (If not mentioned, state "Haemodynamically stable, abdomen soft/non-tender, pelvis stable, no fractures, no active bleeding.") D: [Disability including GCS breakdown E/V/M, pupils, focal neurology] (If not mentioned, state "GCS 15/15, PEARLA, moving all limbs, no focal neurology.") E: [Exposure including log-roll findings, spinal tenderness/deformity, rectal exam] (If not mentioned, state "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: [Immediate airway management] (Only include if explicitly mentioned; otherwise omit completely.) - B: [Ventilation/oxygenation management, intubation details if applicable] (Only include if explicitly mentioned; otherwise omit completely.) - C: [IV access, fluids, blood, inotropes] (Only include if explicitly mentioned; otherwise omit completely.) - D: [Neuroprotective management, neurosurgical consults] (Only include if explicitly mentioned; otherwise omit completely.) - E: [Exposure and temperature management] (Only include if explicitly mentioned; otherwise state "Kept warm, temperature monitored and treated if required.") [Investigations] (Only include if explicitly mentioned; otherwise omit completely.) [Point of care investigations] (Only include if explicitly mentioned; otherwise omit completely.) [Procedures] (Only include if explicitly mentioned; otherwise omit completely.) Secondary Survey: Head: [Scalp/face exam] (If not mentioned, write NAD.) ENT: [Ear/nose/throat exam] (If not mentioned, write NAD.) Eyes: [Eye/ophthalmology exam] (If not mentioned, write NAD.) Neck: [Neck exam] (If not mentioned, write NAD.) Clavicles: [Clavicle exam] (If not mentioned, write NAD.) Chest: [Chest exam] (If not mentioned, write NAD.) Abdomen: [Abdominal exam] (If not mentioned, write NAD.) Pelvis: [Pelvis exam] (If not mentioned, write NAD.) Back: [Back exam] (If not mentioned, write NAD.) Upper limbs: [Upper limb exam] (If not mentioned, write "Bilateral full ROM, NVI, NAD.") Lower limbs: [Lower limb exam] (If not mentioned, write "Bilateral full ROM, NVI, NAD.") [ICD-10 diagnosis codes] (Always include for main and additional diagnoses if explicitly mentioned. If trauma, include mechanism of injury code as well.) Assessment: [Main diagnosis] (Only include if explicitly mentioned; otherwise omit completely.) [Haemodynamic stability] (State based on vitals; do not restate vitals.) [Respiratory distress or failure, type] (Only include if explicitly mentioned; otherwise omit completely.) [Additional diagnoses] (Only include if explicitly mentioned; otherwise omit completely.) DOI [Date/time of injury] (Only include if explicitly mentioned.) MOI [Mechanism of injury] (Only include if explicitly mentioned.) Differential: [List differential diagnoses from most likely to least likely, only if explicitly mentioned.] Continued Management Plan: - Managed according to ATLS principles [Medication details] (Only include if explicitly mentioned; otherwise omit completely.) [Investigations] (Only include if explicitly mentioned; otherwise omit completely.) [Blood tests] (Only include if explicitly mentioned; otherwise omit completely.) [Procedures] (Only include if explicitly mentioned; otherwise omit completely.) [Counselling details] (Only include if explicitly mentioned; otherwise omit completely.) [Shared decision making with patient/family] (Only include if explicitly mentioned; otherwise omit completely.) [Specialist discussion details] (Only include if explicitly mentioned; otherwise omit completely.) [Review plan details] (Only include if explicitly mentioned; otherwise omit completely.) [Disposition details] (Only include if explicitly mentioned; otherwise omit completely.) [Outpatient specialist referral details] (Only include if explicitly mentioned; otherwise omit completely.) [Outpatient GP referral details] (Only include if explicitly mentioned; otherwise omit completely.) [Follow up plan details] (Only include if explicitly mentioned; otherwise omit completely.) (Use date format dd/mm/yyyy and time format hh:mm. Replace the word "query" in transcript with "?" immediately before the suspected diagnosis/word. Use only abbreviations explicitly permitted: DC, TTO, MOI, DOI, DW, NAD, NVI, ROM, RA, NPO2, FMO2, FiO2, USS, CXR, ECG, ml/hr, mcg/kg/min, PEARLA. Do not abbreviate medical conditions.) (For each section, only include if explicitly mentioned in transcript or contextual notes, else omit section entirely. Never create your own patient details, diagnoses, assessments, interventions, or plans—use only transcript, contextual notes, or clinical note as reference. If information has not been explicitly mentioned, do not state it; simply omit.)