Trauma Tertiary Survey Note

Date/Time of Tertiary Survey: [Date and time]

Hospital Day / Hours Since Arrival: [Hospital day and hours since arrival]

Examiner: [Role and name]

Supervising Clinician: [Name and role] (Omit line if not applicable)

Tertiary survey performed to identify delayed or missed injuries and reconcile exam findings with final imaging interpretations.

Exam Reliability & Patient Context

Mental status: [awake and cooperative / sedated / intubated / altered / other]; Ability to provide history: [reliable / limited / unable due to (reason)]

Exam limitations: [Factors limiting examination such as sedation, spine precautions, splints, dressings, agitation, or "none"]

Exam reliability: [high / moderate / limited] — [Brief rationale]

Deferred regions: [Regions not assessed, reason, and plan to reassess] (Omit if none)

New symptoms since admission: [Patient-reported pain sites, neurologic symptoms, other concerns] (If patient cannot provide reliable report, state "Unable to provide reliable symptom report due to [reason]" rather than documenting denials)

Relevant interval events: [Procedures, new symptoms with mobilization, hemodynamic changes] (Omit if none)

Physical Examination

(Document systematic head-to-toe, front-to-back exam. For any region not assessed, state "not assessed" or "deferred" with reason rather than documenting a normal finding.)

Head/Face/Neck: [Scalp, face, oral cavity inspection and palpation; cervical spine with collar status; midline tenderness; if c-spine clearance deferred, state reason and plan]

Chest: [Chest wall tenderness, crepitus, breath sounds, work of breathing]

Abdomen/Pelvis: [Tenderness, guarding, distension, seatbelt sign; pelvic stability if assessed; perineal exam if indicated or state "not indicated"]

Back/Spine: [Confirm posterior exam performed; thoracolumbar inspection and palpation; if deferred, state reason and plan to reassess]

Extremities: [All four extremities: inspection, palpation, neurovascular status (pulses, sensation, motor); specifically address hands/wrists and ankles/feet as commonly missed sites; for splinted or casted extremities, document what was assessable and what was limited]

Diagnostic Review

(Summarize key findings; do not paste full reports.)

Imaging reviewed: [Modality, body region, preliminary vs final interpretation status, key findings]

Discrepancies between initial and final reads: [Differences identified and actions taken] (Omit if none)

Outside imaging: [Images imported and reviewed / report only / unavailable] (Omit if not applicable)

Pertinent labs: [Hemoglobin trend, hematuria, CK, or other findings influencing injury suspicion] (Include only if relevant to missed-injury detection)

Findings & Plan

Tertiary Survey Outcome: [No new injuries identified on tertiary survey (note any exam limitations)] OR [New injuries identified — see below]

New/Newly Suspected Injuries: (For each injury: how discovered, description with laterality, risk assessment, action taken. For suspected but unconfirmed injuries, document clinical concern and workup plan. Omit section if no new injuries.)

[Injury findings and actions]

Plan: [New imaging/studies ordered; consults (service, reason, urgency); immobilization or weight-bearing changes; disposition implications; or "No new actions required"]

Follow-up: [Timing for repeat tertiary survey if exam limited; pending studies requiring follow-up; responsible clinician]

Notifications: [Who was notified of new findings] (Include only if new injuries identified)