Trauma Surgery Admission H&P

Date/Time of Note: [Date and time of note entry]

Date/Time Patient Seen: [Date and time patient evaluated by trauma team]

Author/Service: [Name, credentials, Trauma Surgery Service]

Attending of Record: [Attending surgeon name]

Patient Location: [ED / ICU / Floor]

Trauma Activation Level: [Level 1 / Level 2 / Level 3] (Omit this line if not a trauma activation.)

Transfer Status: [Scene arrival / Transfer from facility name] (If transfer, include transport mode.)

Mechanism: [Blunt / Penetrating / Burn / Other] — [Brief mechanism descriptor]

Chief Concern

[Chief concern in patient's words when feasible]; admitted to trauma service for [reason for admission]. (If patient cannot provide history, use mechanism-based concern and note the limitation.)

History Source & Limitations

[Sources: patient / EMS / family / outside records / pharmacy]. [Limitations: intubation / altered mental status / intoxication / sedation / language barrier / dementia]. (If interpreter used, note language and modality. If history significantly limited, include baseline cognition or functional status if available.)

History of Present Illness

[Mechanism summary and key injuries, beginning with most critical. Include time of injury, time of arrival, and transfer timeline if applicable.]

[Mechanism-specific details: For MVC—restraints, airbags, intrusion, rollover, ejection, speed, extrication time, fatalities at scene. For falls—height, surface, syncope suspicion, head strike, baseline mobility. For penetrating—weapon type, number of wounds, range, prehospital hemorrhage control.]

[Prehospital course: initial mental status, hypotension or hypoxia, tourniquets, pelvic binder, fluids or blood, airway interventions.]

[ED stabilization: airway/ventilator status and indication; hemodynamics and resuscitation including fluids, blood products, massive transfusion if applicable; key procedures; medications given including TXA, antibiotics, tetanus, reversal agents.]

[Current symptoms: pain locations, neurologic symptoms, dyspnea, abdominal pain, weakness, numbness.]

[Anticoagulation and bleeding risk: agent name, indication, last dose time, adherence, renal function if relevant to clearance.] (Do not infer absence of anticoagulation from normal coagulation labs. For unknown items, explicitly state "Unknown" with reason.)

[Baseline function: ambulatory status, ADLs, cognitive baseline.] (Especially important for geriatric patients or head injury.)

Past Medical History

• [Cardiopulmonary conditions: CAD, HF, COPD, OSA, home oxygen]
• [CKD or ESRD]
• [Cirrhosis or chronic liver disease]
• [Diabetes]
• [Seizure disorder]
• [Prior stroke/TIA, dementia, or cognitive impairment]
• [Bleeding or clotting disorders]
• [Indwelling devices: pacemaker/ICD, VP shunt, vascular grafts]
• [Pregnancy status] (If applicable.)
• [Other relevant comorbidities]

(If unobtainable, state "PMH unknown—history limited due to [reason].")

Past Surgical History

• [Prior abdominal surgery]
• [Spine surgery]
• [Craniotomy or neurosurgical procedures]
• [Vascular grafts or endovascular repairs]
• [Orthopedic hardware]
• [Other pertinent surgeries]

Medications

• [Anticoagulants/antiplatelets: name, indication, typical schedule, last dose time, reversal status if given]
• [Insulin and glycemic regimen]
• [Chronic steroids or immunosuppressants]
• [Opioids and home pain regimen]
• [Anticonvulsants]
• [Beta-blockers or other high-risk agents]
• [Other chronic medications]

(If list incomplete, document what is known and plan to reconcile.)

Allergies

Allergies: [Drug allergies with reaction type: true allergy vs intolerance; include contrast allergy if relevant] (If unknown, state "Allergies unknown—treat as unknown risk until verified.")

Social History

• [Living situation and supports]
• [Baseline ambulation and assistive devices]
• [Tobacco use status]
• [Alcohol use and screening status]
• [Substance use and screening status]
• [Occupation or functional baseline]

(For minors or vulnerable adults, document objective safety observations and actions taken if applicable. If unobtainable, state "Unable to obtain; will reassess.")

Review of Systems

[Focused ROS aligned to injuries and mechanism: neuro, respiratory, GI, MSK, and other pertinent systems.] (Avoid exhaustive multi-system negatives. If unobtainable, state "ROS unobtainable due to [intubation / altered mental status / sedation].")

Physical Examination

Vital Signs: [HR, BP, RR, SpO2, Temp with times; include trends if relevant]

Ventilator Settings: [Mode, FiO2, PEEP, TV, rate] (Only if intubated.)

General

[Appearance, distress level, sedation level, C-collar/backboard status, splints, pelvic binder, oxygen delivery]

Primary Survey Status

• Airway: [Patent / Intubated with tube depth and confirmation]
• Breathing: [Work of breathing, breath sounds, chest wall tenderness or crepitus]
• Circulation: [Pulses, perfusion, active bleeding, hemodynamic status]
• Disability: [GCS (E__ V__ M__), pupils, focal deficits]
• Exposure: [Temperature, global skin findings]

Secondary Survey

• Head/Face: [Lacerations, deformities, tenderness, periorbital findings]
• Neck: [Tenderness, deformity, soft tissue findings, tracheal position]
• Chest: [Inspection, palpation, auscultation; rib/sternal tenderness; subcutaneous emphysema]
• Abdomen: [Soft/firm, tenderness, distension, peritonitis]
• Pelvis: [Stability, tenderness] (Do not reassess mechanical stability if known unstable.)
• GU/Perineum: [Blood at meatus, scrotal/labial findings, rectal tone, gross hematuria] (As indicated.)
• Extremities: [Deformities, tenderness, ROM; neurovascular status of injured limbs: motor, sensation, pulses, compartments]
• Back/Spine: [Tenderness, step-offs, wounds] (Logroll with precautions if spine not cleared.)
• Skin/Wounds: [Locations, sizes, contamination, hemostasis, dressing status]

Spine Precautions: [Cleared / Not cleared—reason: pain / intoxication / distracting injury / neurologic deficit / incomplete imaging]

(If any portion of exam is limited, document why and plan to complete.)

Diagnostics Reviewed

Laboratory Data

[Pertinent labs with values and times: CBC trends, lactate or base deficit, INR/PTT, type and screen/crossmatch status, creatinine, other relevant results.] (Use trends where relevant; do not paste full panels.)

Imaging

• [Modality, body region, date/time]: [Preliminary / Final read] — [Salient findings with injury descriptors; key negatives affecting management] (Note if independently reviewed.)

(Repeat for each study.)

Incidental Findings: [Finding; whether communicated; follow-up plan (inpatient vs outpatient); responsible party]

Critical Results Communication: [When and to whom critical results were communicated]

Procedures and Consults in ED

• Procedures: [Procedures performed with brief outcomes]
• Consults: [Services engaged with key recommendations]

Injury List

(For each injury: name and laterality, grade/classification if available, supporting study, confirmed vs suspected, responsible service. Omit regions clearly evaluated with no injuries. If still under evaluation, state "Injuries under evaluation.")

• Head/Neuro: [Injury, grade, imaging, confirmed/suspected, service]
• Face/ENT: [Injury details]
• Spine: [Injury details]
• Chest: [Injury details]
• Abdomen/Pelvis: [Injury details]
• GU: [Injury details]
• Extremities: [Injury details]
• Skin/Wounds: [Injury details]
• Other: [Hypothermia, rhabdomyolysis, etc.]

Assessment

[Synthesis: mechanism, physiologic status, top injuries, significant comorbidities (especially anticoagulation), immediate threats, and planned level of care.]

Key Risks: [Bleeding risk / Airway risk / Delirium risk / Aspiration risk / Need for OR / Need for ICU] (Include only applicable risks.)

Plan

[Problem 1: Diagnosis or clinical impression]

• Status: [Current clinical status and priorities]
• Diagnostics: [Planned tests or monitoring with reassessment timeframes]
• Therapeutics: [Interventions, procedures, medications with doses]
• Consults: [Services involved, clinical questions, escalation triggers]
• Activity/Diet: [Implications for activity, weight-bearing, and diet]
• Holds: [Items on hold with reason and reassessment trigger]

[Problem 2: Diagnosis or clinical impression]

• [As above]

(Add additional problems as needed, organized by descending clinical severity.)

Trauma Admission Orders

• Level of Care/Monitoring: [ICU / Stepdown / Floor]; neuro checks q[frequency]; [Telemetry: yes/no]; [Respiratory monitoring parameters]
• DVT Prophylaxis: Mechanical: [Yes / No—reason]; Pharmacologic: [Agent, dose, start time] or [Contraindication/hold reason with reassessment trigger]
• Diet: [NPO / Regular / Enteral feeding plan]; [Swallow evaluation if indicated]
• Activity: [Bedrest / Up with assistance]; [Weight-bearing status by limb]; [Spine precautions]; [PT/OT consult]
• Pain Management: [Multimodal regimen]; [Regional anesthesia consult if indicated]; [Bowel regimen if opioids]
• Pulmonary Hygiene: [IS goals]; [RT involvement] (If chest injury, intubation risk, or prolonged immobility.)
• Antibiotics: [Indication and agent] (For open fractures, contaminated wounds, hollow viscus concern.)
• Tetanus: [Up to date / Administered / Unknown—plan to verify]
• Glycemic Management: [Targets and insulin plan] (If diabetic or critically ill.)
• Lines/Tubes/Drains: [Type, indication, removal goals]
• Disposition Goals: [Anticipated barriers]; [Target discharge location]

Consults and Communication

• Consults Requested: [Service and clinical question]
• Family Communication: [Notification status; surrogate decision-maker and contact if applicable]
• Ancillary Services: [Case management/social work triggers]
• Transfer Records: [Outside facility image/data transfer status] (If transfer patient.)

Safety and Follow-up

• Anticoagulation Management: [Hold / Reversal / Restart plan]; [Monitoring plan with labs and timing]
• Substance Use Screening: [Screening status; brief intervention or referral if indicated]
• Fall/Delirium Precautions: [Precautions for at-risk patients; non-pharmacologic strategies]
• Code Status: [Full code / DNR / DNI / Unknown—plan to clarify]
• Tertiary Survey: [Plan for tertiary exam and imaging review within 24 hours; separate note: yes/no]

Signature

[Electronic signature with credentials]

(Meta-instructions: Use explicit timestamps for injury time, arrival, last anticoagulant dose, and key interventions. Label clinical suspicions as such and pair with evaluation plan. Summarize labs and imaging interpretively—do not paste raw reports. Do not infer absence of anticoagulation from normal coagulation labs. For unknown high-safety items—allergies, anticoagulants, code status, pregnancy status, tetanus status, neurologic baseline—state "Unknown" rather than omitting. Avoid dangerous abbreviations: no trailing zeros, no "U" for units, no "QD.")