Need help with original trauma note

Dixielee, BSN, RN · Nov 24, 2005

I am not entirely clear what you are asking, but I will try to answer. Most trauma sheets I have seen leave very little narrative to be written. Most have blocks of information that more or less are connected. Generally the first is pre hospital info such as what EMS service, mechinism of injury info, types of injuries, etc, interventions, i.e. intubated, immobilized, meds, and responses, vital signs etc. Then who was notified and when, such as surgery, trauma surgeon, neuro, etc. Then who is on trauma team, i.e. ER doc, what nurses, primary, secondary and recorder, RT, etc.

When the patient arrives, you will get face to face EMS report and can then put GCS, trauma score, vitals, times of interventions, types of tubes, lines, injuries, etc. Usually you will have a drawing of front and back of patient and can draw in rather then describe every injury. You will have a place to put all the updated prehospital stuff that may have changed since you got radio report.

If you are in a good hospital, you will not have to do the paperwork and the patient care by yourself. If you do, then you are just out of luck, because it can't be done. To do it with any sort of efficiency and decent outcomes, you must have several doing the hands on stuff and a recorder. The ones doing the hands on stuff SHOULD be calling out information for all to hear as it is noted or done, such as breath sounds, bleeding sites, level of consciousness, pupils, airway patency, etc. Any blood draws, additional lines, fluids, blood transfusions, catheters, urinary output,chest tubes, etc. should also be noted for you to document.

A head to toe assessment will be done and you must note things as they are examined. Anyone else who intervenes, i.e Resp Therapy, surgeons, etc. will be noted, as well as what time each were called and when they arrived. If no one is giving you info, you must ask for it. Don't be shy, sometimes people are just busy and involved and don't think about the recorder. There should be a constant dialogue going on. Everyone needs to be aware of each others actions. There is no time to do extra work that someone else has already done.

It all moves very fast if all goes well. When the patient is wisked off to CT, the recorder can catch up on paper work if needed. I have had patients go off to OR before the paperwork is finished, but you just get it done ASAP, copy it per department protocol and get it to the OR or wherever the patient is going.

Trauma paperwork can be confusing, but everything should be there, with little narrative. There should be places for vital signs, meds, and updates for GCS, trauma scores, I/O's, fluids, lines etc. Don't worry about being redundant. If it is charted once, that is enough. You don't have to summerize, even though we are prone to want to. Be sure to document times people are called, things that are done, and when and where the patient went and with who as well as changes in condition. Anything you can't find a spot for, then put in your narrative.

I hope this is not too confusing, I have been awake almost 24 hours and am heading to bed. Good luck, it gets easier, but only if you have adequate help, and a decent system.

Aneroo, LPN · Nov 24, 2005

Great ideas!

One of our preceptors would do this: She brought her orientee into trauma. They both recorded the trauma. One was the real notes, another was practice. That way later on they could compare notes, the orientee could practice in a real setting.

I still have to jot stuff down on a piece of paper, then go back and write it. I jsut can't seem to find all of the blocks at the same time.

And yes, you do have to get loud. Shouting "Did anyone check this!?" is not uncommon.

-Andrea