Trauma History and Physical - PageOut

that is directly relevant to the medical care of the individual. We all like a good story, but themedical record is not the appropriate place for them.• Do not describe people involved other than the patient; i.e. do not document that the patientstated "his girlfriend shot him".• Do not describe aspects of MVAs that indicate "fault", i.e. do not document "a car ran a redlight and hit patient's car."• Do not describe people, including patient, as a "drug dealer, pimp, assailant," etc.• Do not document second-hand information that does not contribute to the medical care of thepatient.• Do not document aspects of the MOA in a way that place blame/fault in a legal sense onpeople involved directly or indirectly in events.• Do no describe injuries as self-inflicted• Do not assign exit or entrance wounds when there is more than one GSW4) Pre-Hospital Carea) How transported (ambulance, air, personal car)b) What medical intervention was given up to this point (fluids, monitoring, backboard, C-collar)c) Has the patient, at any time, been unconscious, hypotensive or dropped oxygen saturationd) Was the patient transferred or brought from the scene5) How is the Patient Now?a) Awake, alert and oriented to person, place, time?b) Confused?c) Respiratory distress?d) Is the patient able to interact and communicate?PMH: self-explanatoryPSH: self-explanatoryMeds: including aspirin, BC powder, Goodies, Coumadin, Plavix, etc. (These can all predisposeto bleeding)Allergies: self-explanatorySpecific Mechanism of Action and What to Include:MVA• Driver/passenger; front/back seat• Seatbelt? Airbag? Shoulder harness?• Speed• Damage to vehicle, with specific location of patient in relation to damage/impact.• Loss of Consciousness? (LOC)• Was the seat back, windshield or steering wheel broken?• Were there any fatalities in the accident?• Were others injured in the accident?• Prolonged extrication?