Splinting/Spinal Motion Restriction Procedure Note (EMS)

Date/Time: [Date and time procedure completed]

Performed by: [Crew member name(s) and certification level(s)]

Authorization: [Standing protocol / Online medical direction: [physician name, time, orders] / On-scene physician: [name, affiliation]]

Procedure Type

[Spinal Motion Restriction (SMR) / Extremity Splint Application / Pelvic Binder / Other: [specify]] (Select all that apply. If more than one procedure was performed, complete a separate Procedure block for each.)

SMR Not Performed

(Include this section only when SMR was considered but not applied. If SMR was performed, omit this section.)

• Decision: [SMR not indicated per protocol / Deferred due to competing priority / Not performed due to patient factors / Patient refusal]
• Objective rationale: [Specific protocol criteria and objective findings supporting the decision] (List explicit findings; do not infer normal if not assessed.)
• Capacity and informed decision: (If refusal) [Assessment of decision-making capacity, risks explained, patient's stated reason]
• Medical direction consulted: [Yes: [details] / No]

Procedure #1

(Duplicate this Procedure block for each procedure performed and update numbering.)

Procedure: [Spinal Motion Restriction (SMR) / Extremity splint: [left/right] [anatomic region] / Pelvic binder / Other: [specify]]

Indication

[Brief indication narrative] (1–3 sentences describing mechanism/context and clinical reason for immobilization. For extremity splinting: suspected fracture/dislocation, deformity, instability, pain with movement, neurovascular protection, or post-reduction stabilization. For SMR, explicitly list protocol trigger(s): altered mental status or unreliable exam, midline spine pain or tenderness with location, focal neurologic symptoms with distribution, spinal deformity, distracting injury, or communication barrier. Identify source if information is from bystanders or other responders.)

Pre-Procedure Assessment

(Document only findings actually assessed. Do not infer normal status. If unable to assess, state "Unable to assess—reason: [reason]". Spell out neurovascular findings rather than using abbreviations.)

• Extremity-focused assessment (Complete for extremity splinting)
  • Distal pulse: [present/absent/diminished]; quality: [strong/weak/thready]
  • Capillary refill: [seconds] (if assessed)
  • Skin color/temperature distal to injury: [description]
  • Motor function of distal joints: [movements tested and results]
  • Sensation distal to injury: [intact/decreased/paresthesias/numbness]; distribution: [specify]
  • Open wounds/bleeding/skin condition at splint site: [description]
• SMR-focused assessment (Complete for spinal motion restriction)
  • Midline spine tenderness: [yes/no]; location: [cervical/thoracic/lumbar]
  • Focal neurologic symptoms: [none / description with distribution]
  • Gross motor: [findings by limb]
  • Gross sensation: [findings by limb]
  • Mental status/exam reliability: GCS [value]; intoxication: [yes/no]; communication barrier: [description]; distracting injury: [yes/no]
• Pain score: [0–10 or age-appropriate scale] at [location] (If unable to assess—reason: [reason])

Procedure Details

• Extremity splint application (Complete for extremity splinting)
  • Device type: [rigid splint / SAM splint / vacuum splint / traction splint / pillow splint / other: [specify]]
  • Immobilization extent: joint above: [yes/no]; joint below: [yes/no]
  • Padding: [description or none]
  • Alignment: [position of function / neutral alignment / other: [description]]
  • Secured with: [cravats/elastic wraps/straps/tape/other]
  • Realignment performed: [no / yes: technique, outcome, neurovascular status during maneuver]
  • Adjuncts: [analgesia: [drug, dose, route, time] / ice applied / none]
• Spinal motion restriction (Complete for SMR)
  • Cervical collar: [type]; size: [size]; fit verified: [yes/no]
  • Transport surface: [ambulance cot / vacuum mattress / scoop stretcher / other: [specify]]
  • Head stabilization: [head blocks / rolled towels / head strap / manual stabilization / not applicable]
  • Patient position: [supine / other: [description]]; alignment: [neutral / other: [description]]
  • Transfer/extrication: manual inline stabilization: [yes/no]; aids used: [description]
  • Long board: [not used / extrication-only / continued during transport]; rationale: [description]
  • Pediatric accommodations: [shoulder padding for neutral alignment / other / not applicable]
• Pelvic binder/other device (Complete if applicable)
  • Device: [type]; placement: [landmarks and positioning]; securing method: [description]

Post-Procedure Reassessment

(Compare explicitly to baseline. Document corrective action if any worsening.)

• Extremity-focused reassessment (Complete for extremity splinting)
  • Distal pulse: [unchanged/improved/diminished]; current: [description]
  • Motor function: [unchanged/improved/worsened]; current: [description]
  • Sensation: [unchanged/improved/worsened]; current: [description]
  • Corrective actions: [none needed / loosened/adjusted/removed device / contacted medical direction; outcome: [description]]
• SMR-focused reassessment (Complete for spinal motion restriction)
  • Neurologic status vs baseline: [unchanged/improved/worsened]; details: [gross motor and sensation by limb; any new symptoms]
  • Complications during SMR: [none / nausea / vomiting / respiratory difficulty / pressure discomfort / anxiety]; management: [description]
• Pain score after procedure: [value]; change: [improved/unchanged/worse]
• Patient tolerance: [Specific observations: comfort, anxiety level, breathing ease, complaints such as tightness/pinching/numbness/pressure]
• Procedure response: [improved / unchanged / worse] (Support with objective findings above.)

Complications

(If no complications and procedure carries higher risk, explicitly note stability.)

• [No complications; neurovascular/neurologic status remained stable] OR
• Complication: [new/worsened paresthesias / pulse change / pain out of proportion / pressure injury concern / equipment issue / inability to maintain alignment / other]; clinical effect: [description]; corrective action: [description]; outcome: [description]

Handoff

Device status on ED arrival: [in place and intact / adjusted / removed at ED request]

Current neurovascular/neurologic status: [findings by limb]

Pain level: [value]

Concerns communicated to receiving staff: [pressure points / need for frequent neurovascular checks / device-related concerns / none]

(Documentation reminders: Use "spinal motion restriction" terminology. Spell out neurovascular findings. Do not infer normal status if not directly assessed. State "Unable to assess—reason:" when information cannot be obtained. Identify information sources if not the patient.)