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Discipline

: Emergency

Sub Discipline

: Emergency

Document Title

: ETD Trauma Clerking Note

Admission History

Date of Admission

Time of Admission

Age of Admission

Type of Admission

Medico Legal Case

YesNo

Police Report No

INJURY DETAILS

Date Of Injury

Age At Injury

Type Of Injury

Injury Intent

Mechanism of Injury

Place Of Injury

Activity

Emergency Medical System (Ems)

Mode of Transport to Hospital

Ambulance

PRIMARY SURVEY

Airway And Cervical Protection

General Condition

Mental Status

Airway Patency

Trachea

Gag Reflex

Cervical Spine Immobilisation

None

Cervical Collar

Head Immobilizer

Manual Cervical Immobilisation

Spinal Board

Scoop Strecher

Others, specify

Airway-Management

Head tilt chin lift

Chin lift

Jaw thrust

Removal of foreign body

Suction

Bag-Mask

Oropharyngeal airway

Nasopharyngeal airway

Laryngeal mask airway

Laryngeal tube

Combitube

Endotracheal tube

Tracheostomy

Needle cricothyroidostomy

Surgical cricotyhroidostomy

Others, specify

Airway Delivery

Breathing

Respiratory Rate

Comment

Inspection

Normal

Deformed

Bruise

Abrasion

Laceration

Puncture wound

Others, specify

Comments

Chest Movement

Palpation

Non tender

Tender

Chest Spring positive

Chest Spring negative

Subcutaneous emphysema

Others, specify

Percussion

Normal

Hyperresonant left

Hyperresonant right

Dull right

Dull left

Others, specify

Auscultation

Normal

Reduce on right

Reduce on left

Reduce both

Prolonged expiratory

Absent

Others, specify

Adventitious Sound

Crackles

Rhonchi

Pleural rub

Nil

Others, specify

Breathing Management

Spontaneously

Three sided occlusive seal

Bag mask ventilation

Needle thorachostomy right

Needle thorachostomy left

Needle thorachostomy both

Chest tube right

Chest tube left

Chest tube Both

Ventilated

Others, specify

CIRCULATION

Skin Color

Capillary Refilling Time

Peripheral Circulation

Neck Vein

Heart Sound

External Haemorrhage

Abdomen

Distended

Pelvic

Pelvic Spring

Circulation Management

IV Access

Right Upper Limb

Size

Left Upper Limb

Size

Right Lower Limb

Size

Left Lower Limb

Size

Right Jugular

Size

Left Jugular

Size

Right Femoral

Size

Left Femoral

Size

Scalp Vein

Size

Miscellaneous

Central Venous line

Venous Cut Down

Intraosseous

Others, specify

Fluid

Crystalloid

Colloid

Dextrose

FFP

Platelet

Cryoprecipitate

Packed Cell

Others, specify

Haemmorhage Control

Pressure bandage

Pressure on Proximal Artery

Raise Limb

Artery Ligation

Others, specify

Immobilisation

Right UL Immobilisation

Left UL Immobilisation

Right LL Immobilisation

Left LL Immobilisation

Right Femur Traction

Left Femur Traction

Pelvic Clamp

Others, specify

DYSFUNCTION

Pupils

Please Update Method

GCS

E

V

M

:

COMPLAINT AND HISTORY

Current Complaint

History Of The Incident

Past Medical And Surgical History

Drug History

Personal And Family History

Menstrual History

LMP

Other O&g History

PHYSICAL EXAMINATION

Physical Examination

Other Injuries

Comments

PHYSICAL EXAMINATION (SYSTEMIC)

Vital Signs

Systemic Review

Cardiovascular System (CVS)

NormalAbnormal

Respiratory

NormalAbnormal

Abdomen

NormalAbnormal

Cns

NormalAbnormal

Skin And Lymph Node

NormalAbnormal

Genitourinary

NormalAbnormal

INVESTIGATION

Glucometer

mmol/L

ECG Findings

Radiological Investigation

Bedside Ultrasound / Echocardiography

Laboratory Investigation

Other Findings

DIAGNOSIS

Diagnosis

MANAGEMENT

Plan

Orders

Referral

Outgoing Referrals

Others

SIGNATURES

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