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ETD Trauma Clerking Note

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Admission History

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Date of Admission

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Time of Admission

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Age of Admission

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Type of Admission

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Medico Legal Case

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INJURY DETAILS

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Date Of Injury

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Age At Injury

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Type Of Injury

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Injury Intent

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Mechanism of Injury

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Place Of Injury

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Activity

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Emergency Medical System (Ems)

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Mode of Transport to Hospital

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PRIMARY SURVEY

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Airway And Cervical Protection

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General Condition

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Mental Status

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Airway Patency

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Trachea

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Gag Reflex

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Cervical Spine Immobilisation

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Airway-Management

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Airway Delivery

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Breathing

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Respiratory Rate

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Comment

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Inspection

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Comments

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Chest Movement

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Palpation

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Percussion

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Auscultation

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Adventitious Sound

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Breathing Management

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CIRCULATION

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Skin Color

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Capillary Refilling Time

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Peripheral Circulation

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Neck Vein

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Heart Sound

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External Haemorrhage

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Abdomen

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Pelvic

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Pelvic Spring

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Circulation Management

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IV Access

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Right Jugular

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Left Jugular

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Right Femoral

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Left Femoral

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Scalp Vein

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Miscellaneous

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Fluid

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Haemmorhage Control

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Immobilisation

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DYSFUNCTION

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Pupils

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GCS

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E

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V

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M

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:

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COMPLAINT AND HISTORY

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Current Complaint

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History Of The Incident

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Past Medical And Surgical History

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Drug History

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Personal And Family History

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Menstrual History

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LMP

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Other O&g History

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PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION (SYSTEMIC)

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Vital Signs

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Systemic Review

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Cardiovascular System (CVS)

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Respiratory

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Abdomen

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Cns

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Skin And Lymph Node

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Genitourinary

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INVESTIGATION

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DIAGNOSIS

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MANAGEMENT

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Plan

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Orders

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Referral

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Outgoing Referrals

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Others

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SIGNATURES

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