EM Trauma note

ER Trauma Note Time of Assessment: [Time of assessment as documented in transcript or patient details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Use format HH:MM.) Patient: [Patient age and gender] (Only include if explicitly mentioned in transcript or patient details, else omit entirely. Write as a brief demographic descriptor e.g. 32-year-old male.) --- HPI [Description of trauma mechanism including mechanism of injury, protective equipment used such as helmet or seatbelt, loss of consciousness, and associated symptoms such as vomiting, amnesia or confusion] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences in paragraph format.) --- AMPLE Allergies: [Known allergies including allergen and reaction type] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a list.) Medications: [Current medications including dose and frequency] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a list.) Past Medical History: [Relevant past medical and surgical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a list.) Last Meal: [Time and content of last oral intake] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Events Leading to Presentation: [Mechanism of injury and pre-hospital course including any interventions by EMS] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) --- Primary Survey (ABCDE) A - Airway [Airway status, cervical spine precaution status, and any airway interventions performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write each finding on its own line.) B - Breathing [Respiratory rate, oxygen saturation, breath sound findings, chest wall findings, and any oxygen or ventilatory support in use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write each parameter on its own line.) C - Circulation [Heart rate, blood pressure, temperature, skin perfusion findings, bleeding status, intravenous access details, fluids or blood products administered, abdominal findings, and pelvic stability] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write each parameter on its own line.) D - Disability [Glasgow Coma Scale score broken down by eye, verbal and motor components, blood glucose level, pupil size and reactivity, and neurological findings including motor and sensory status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write each finding on its own line.) E - Exposure and Environment [Injuries identified on full exposure including lacerations, bruising, deformities or other findings, and temperature management measures taken] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write each finding on its own line.) --- Secondary Survey Head and Neck: [Findings on head and neck examination including lacerations, deformities, step-offs or active bleeding] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Chest: [Chest wall tenderness, bruising, or seatbelt sign] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Abdomen: [Abdominal findings including tenderness, distension or ecchymosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Pelvis: [Pelvic stability on examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Back: [Findings on log-roll examination including step-offs or midline tenderness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Extremities: [Range of motion, deformities, and neurovascular status of all limbs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) --- Investigations Ordered Labs: [Blood tests ordered including full blood count, venous blood gas, INR, creatinine, type and screen, or other relevant investigations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a list.) Imaging: [Imaging ordered including FAST ultrasound, CT head, CT cervical spine, chest X-ray, CT abdomen and pelvis, or other studies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a list.) ECG: [Whether ECG was performed and any relevant findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Urine: [Urine investigations ordered including pregnancy test or toxicology screen] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) --- Working Impression [Summary diagnostic impression or differential diagnoses based on mechanism, examination and investigations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) --- Plan [Management plan including ongoing monitoring, analgesia prescribed, tetanus status review, specialist consults requested, and patient disposition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write each management point on its own line.)