Clinical template
Trauma Assessment Template
Trauma documentation follows the survey you actually ran: primary (ABCDE), then secondary (head-to-toe plus AMPLE), then a plan that names imaging, consultants, and disposition. This template is for the chart in an emergency department or trauma bay. It is not a substitute for ATLS, your local trauma protocol, or a course card. Findings here are fictional and kept clinical, not graphic.
What the note has to reconstruct
The next clinician — ICU, surgery, or you at 04:00 — needs to know the mechanism, the times, what was abnormal on primary survey, what you did about it, and what the secondary survey added. ATLS order is the spine of the note even if your EMR has a trauma navigator. If you interrupted the survey to intubate, write that interruption. Do not write a textbook primary survey you did not perform.
Canadian centres vary: some are lead trauma hospitals with a team activation; some are community EDs that stabilize and transfer. The documentation job is the same. Include the time of injury if known, time of arrival, time of each major intervention, and who was in the room (team leader, airway, circulating). CMPA's usual rule applies: if a finding or a procedure is not in the record, it is hard to show it happened.
Fictional, not graphic
The example below uses made-up times and findings from a blunt mechanism. It does not describe wounds in detail. Do not paste it into a real chart.
Blank trauma survey template
Trauma assessment — ED / trauma bay
Date / arrival time / injury time (if known): Location: ED bay / trauma room | Team leader: Activation level (if used): Patient: [initials, age, sex] | Identifier confirmed: Mechanism (blunt / penetrating / burn / other — facts only): Prehospital: vitals, interventions, ETA notes, blood products en route: Allergies / anticoagulants if already known: PRIMARY SURVEY (with times) A — Airway / C-spine: patent / adjunct / intubated (time, drugs, ETT size, confirmation). C-spine precautions: B — Breathing: rate, SpO2, chest rise, oxygen/ventilation, needle/chest tube if done (time, side): C — Circulation: HR, BP, access, pelvis binder, haemorrhage control, blood products (time, type): D — Disability: GCS (E/V/M), pupils, glucose, moving all four: E — Exposure / environment: log-roll findings in brief, temperature, warming, clothes off: Adjuncts during primary: CXR / pelvis XR / FAST (time, result in one line): Massive transfusion / TXA / other peri-primary meds: SECONDARY SURVEY AMPLE: Allergies, Meds, Past history, Last meal, Events/environment: Head / face / neck: Chest: Abdomen / pelvis / perineum: Back / flanks (log-roll if not already): Extremities / neurovascular: Skin / temperature: Investigations VBG/ABG, Hb, lactate, INR, βhCG, ECG, TOX as indicated: CT / OR / IR decision: Problems list (numbered) 1. Plan Airway / vent: Blood / reversal / TXA: Consults (time called / time arrived): Imaging pending: Disposition: OR / ICU / ward / transfer (destination, accepting MD, time): Family update: Reassessment times:
Primary vs secondary — keep them honest
| Survey | Belongs here | Does not belong here |
|---|---|---|
| Primary (ABCDE) | Life threats you found and what you did, in order, with times | A full past medical history, or a normal ankle exam |
| Adjuncts | CXR, pelvis film, FAST, monitoring, lines that happened during primary | CT reports that came back an hour later, unless you note the delay |
| Secondary | AMPLE, head-to-toe, missed injuries, tetanus, more history from EMS or family | Repeating the intubation note as if it happened on secondary |
| Plan | Named consultants, named destination, outstanding results, next vitals | 'Continue to monitor' with no owner |
GCS is eyes, verbal, motor — write the parts. 'GCS 10' without a breakdown is weaker than E2 V3 M5. Pupils and glucose sit with disability. If the patient is intubated, say whether that was a crash airway or a planned sequence, and how you confirmed tube position. Laterality for chest tubes and pelvic binders is not optional.
Transfer notes should include the same survey plus why the patient is leaving, what is in the ambulance, and who accepted. Continuity of care after trauma is a separate problem (handoff, imaging discs, blood bank). Link the disposition line to a proper handover, not a one-word 'transfer.'
Example — blunt trauma, community ED (fictional)
Community emergency department
52-year-old, rural Ontario. Single-vehicle daytime crash, belted. Arrival 14:12. Fictional. Findings stated in survey language only.
Mechanism: daytime, winter road, tree impact, ~60 km/h per EMS. Belted, airbag. Extrication 20 min. No rollover reported. Last meal noon. Prehospital: HR 110, BP 98/60, SpO2 94% NRB, GCS 14 (E4 V4 M6). Collar on. 18G left AC, 1 L crystalloid en route. PRIMARY A 14:12 — patent, speaking, collar remains. No stridor. B 14:13 — RR 24, SpO2 95% 15 L NRB, equal chest rise. No chest decompression. C 14:13 — HR 108, BP 96/58. Second 18G right AC. Pelvis binder applied 14:16 (stable pelvis on exam). No external haemorrhage. TXA 1 g IV 14:18. D 14:14 — GCS 14 E4 V4 M6, pupils 3 mm equal, glucose 6.1, moves all four. E 14:20 — log-roll: midline C-spine tender, no step. Warming blanket. Clothes off. Adjuncts: FAST 14:22 negative. CXR 14:25 — no pneumothorax, no wide mediastinum on portable. Pelvis XR 14:26 — no obvious disruption. SECONDARY AMPLE: NKDA. Ramipril. HTN. Last meal noon. Isolated crash, no other occupants. Head/face: frontal abrasion, no Battle sign. Neck: collar, midline tenderness. Chest: seat-belt mark, equal BS. Abdomen: soft, mild LUQ tenderness. Pelvis: binder, no blood at meatus. Extremities: left forearm swollen, pulses present. Back: no step. Labs pending. CT trauma protocol indicated — radiology 14:40. A 1. Blunt polytrauma, hemodynamically improved after crystalloid, FAST negative. 2. Possible solid-organ injury (LUQ). 3. C-spine not cleared. 4. Possible left forearm fracture. P Keep NRB, serial vitals q15. Blood bank: type and cross 4. Analgesia. CT head/C-spine/chest/abdomen/pelvis. Ortho for forearm after CT. Trauma centre discussion if CT shows solid-organ injury or persistent tachycardia. Family updated 14:35. Reassess after CT.
What goes wrong in trauma notes
- A perfect ABCDE paragraph with no times and no names.
- GCS as a single number after intubation without the pre-intubation score.
- Missing laterality on chest, limbs, or pupils.
- Secondary survey copied from a template with 'normal' in every box after a log-roll that never happened.
- Disposition 'admit' with no service and no accepting staff.
Dictate the survey while it is still in order
Scribeberry can take trauma-bay dictation or a paused ambient recording (with consent where that is appropriate) into this template. You correct times, laterality, and consultants before anything is signed. Smart Push into the EMR you actually use. Pro is $99/month after the free trial.
Frequently asked questions
What is a trauma primary survey?
The primary survey is the ATLS ABCDE sequence: airway with C-spine, breathing, circulation, disability, exposure. The note should record threats found, interventions, and times — not a later head-to-toe exam.
What belongs in the secondary survey?
AMPLE history and a head-to-toe exam once life threats are addressed, plus investigations that were not primary adjuncts. It is where missed injuries and more history land.
Can this template replace ATLS training?
No. It is a documentation scaffold. Team roles, decision to operate, and transfer thresholds come from your training and local protocol.
Does Scribeberry run a trauma survey?
No. It drafts the note from what you say or from a consented recording. You remain responsible for the survey, the times, and the signature.
Templates
