Dec 1, 2010

Trauma note taking

We all have different techniques for keeping track of pertinant assessments. Many people have these Tricks of the trade they do with out second thought. I'd like to share one that I find most useful for the trauma call.

I typically scribe on my left glove all my findings from assessments, so I have the info readily available for a patch report to the ER or nurse report. I found scribing this way inauspicious during a trauma call because of all the dirt, grime, blood and various other substances that typically get on gloves. Also during a trauma I am more likely to change gloves and then lose any info I have scribed.

This Scenario is assuming that your rapid initial assessment has determined that the best course of action allows you to remain on scene with your patient. Let me repeat myself, this is not the proverbial "load and go" yet rather you can "Stay and Play" we are talking about. This technique is rather helpful when remembering all those injuries for later on in the call or after all said and done.

Once the Pt is in the rig and you can focus on your primary detailed physical assessment take a roll of 3 inch tape over lapped vertically 2-3 times. Sectioning it into three areas and place on the cabinets along the patient or the wall/ cabinets behind you. The three sections represent the three sections of the body to focus on in a trauma. Head/Neck, Chest/Arms/ABD and Pelvis/Legs. Now every time you find a injury during  your primary assessment you write the findings on the tape, allowing you to re-evaluate systematically on secondary assessments. This technique also lets you take the findings on these sections into the ER for the staff to see and use.

This is an easy skill to get a young provider to do while you preform the assessments. In the case you are with a driver only, you can use them to scribe for you to help out.

By breaking down a trauma assessment from head to toe you have a record of all the DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling) for all the Non EMS'ers. This will alleviate forgetting any injuries when documenting or when sharing during a report to a nurse.

Now not to say this couldn't be done during a "load and go" depending on various factors, such as transport times, Multiple providers in the back Ect. During those times more important life saving interventions of course  take presidence.

I'm glad to pass this off to my readers for I was passed onto me from a great mentor. She's no longer on the streets but misses it greatly. I hope this bit of info helps, I know it has for me.

Be Safe
Ambulance Junkie

1 comment:

  1. I do something similar with tape like you do... but I put it on my left thigh. Makes it really easy to jot stuff down during transport, and I don't risk throwing it away when I change gloves :)