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Trauma Documentation

Horizontales
Patient identifier that includes name, date of birth and medical record number
Active steps used to prevent hypothermia in trauma patients such as blankets and bear hugger
Physical damage to patient such as abrasions, lacerations and deformities
Destination of the patient after receiving care in the trauma bay (admitted, transferred, discharged)
Rapid administration of blood and blood products
Objective measurements of a patient’s most basic functions such as blood pressure, heart rate, respiration rate and temperature
Equipment used to prevent or minimize injury such as seat belts and helmets
Patient’s physical measurements
Measurement of food and fluids that enter and exit the body
Documented travel times to and from medical ________
When the incident occurred
Assessment which includes patient’s airway breathing circulation and disability
Verticales
Account of a specific event that outlines key details of what happened
Trauma Surgeon, Resident and ED attending are examples
A tool used to determine a patient's level of consciousness
RED, YELLOW, GREEN
Brief description of the main symptom or issue
Systematic evaluation of a trauma patient that takes place after the primary survey and any life-saving interventions
Pre-hospital, Activation, Arrival
Person who documents the trauma flow sheet