DHS ED Trauma

Trauma M = [Insert mechanism of traumatic injury, specifying how the trauma occurred, what caused it, and when the injury took place.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a short sentence.) I = [List injuries as reported by pre-hospital staff or noted during handover, including anatomical locations and nature of injury if described.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in short note form.) S = [Include vital signs observed either by ambulance staff during handover or those first recorded in ED, including HR, BP, RR, SpO2, Temp, GCS, etc if available.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in note form.) T = [List any pre-hospital treatments or interventions performed by ambulance or emergency responders prior to ED arrival, including medications, oxygen, immobilisation, IV access, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief dot-point style.) Primary Survey: [Summarise findings of initial structured trauma assessment, including airway, breathing, circulation, disability and exposure. Include key life threats if present or state if none identified.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in sentence or short paragraph format.) C-Spine: [Include outcome of initial C-spine clearance: whether cleared clinically using a tool like NEXUS, or if unable to clear and why. If imaging required, state intention.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Secondary Survey: Head: [Describe inspection and palpation findings of the scalp and skull.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Face: [Describe findings from examination of the facial bones, eyes, ears, nose and mouth.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Neck: [Include examination findings of the anterior and posterior neck including any deformities, tenderness or signs of vascular or airway injury.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Chest: [Describe inspection, palpation, auscultation and percussion findings, any observed deformities, tenderness, or respiratory asymmetry.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Abdomen: [Include examination findings such as tenderness, distension, guarding, or bruising.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Pelvis: [Document pelvic stability, tenderness or deformity, and any associated signs of injury.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Upper Limbs: [Include any examination findings involving the arms, shoulders, hands or joints such as bruising, swelling, deformities, and range of movement.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Lower Limbs: [Include any examination findings involving the hips, knees, legs or feet such as bruising, swelling, deformities, and range of movement.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Back: [Include findings from log roll or spinal examination, including tenderness, wounds, or deformity.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Neuro: [Include neurological observations such as GCS, pupil response, limb movement, sensation, and reflexes if assessed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief note format.) Assessment: [Summarise clinical findings, assessment of trauma severity, suspected or confirmed diagnoses, likelihood of serious injury, and any factors that may complicate management.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.) Plan: 1) [Document investigations, referrals, imaging, or monitoring planned or initiated.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as numbered points.) 2) [Include treatment or observation strategy including medication, wound care, procedural intervention or observation approach.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as numbered points.) 3) [Include disposition plan, safety netting, admission plan, follow-up or discharge considerations.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as numbered points.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextua