Table 1.
Notes categories and subcategories, percent of all notes, and examples.
| Notes Categories and Subcategories | Examples | ||
|---|---|---|---|
| Patient Values (35%) | Vitals | Heart Rate (HR) | 87 HR; 118; 90s; 19? |
| Respiratory Rate (RR) | 20s; 21; 30; 41 | ||
| Oxygen Saturation (SO2) | 100% sat; 97% RA; 98 | ||
| Blood Pressure (BP) | 117/74; 90/palpable; 100 over 65 | ||
| Pulse | 2+ DP; rad 2+; 2+ bilat. | ||
| Glasgow Coma Score (GCS) | 4, 3, 6 13; GCS: 3; 15; 4+4+6=14 | ||
| Pupils | 5mm sluggish but reactive; 3→2; 4 brisk | ||
| Temperature | 36.6 capillary; 37; 37.2 rectal | ||
| Physical Findings & Symptoms (22%) | WNL; soft; stable; TMs clear; Ø deformities; TTP; pain; cleared |
||
| Location | Tender midline; RUQ tenderness; pain L posterior | ||
| Pre-Hospital Information (12%) | Transport | Est. Arrival Time (ETA) | 10 min |
| Demographics | Age | 2 yo; 7 mo/o; 3 wks; Age 12 | |
| Name | (names spelled out) | ||
| Gender | Male; female | ||
| Weight | 11kg; 120 lbs | ||
| Medical History | PMH 3x concussions; All: cats; H/O Asthma on steroids | ||
| Previous Treatments (e.g., en route, outside hospital) | 100mg fent; CPR; 2 x saline; CT head + neck; PE tubes; intubated | ||
| Mechanism of Injury | Fall 5ft; MVC vs Ped; motorbike vs. SUV | ||
| Physical Findings | Ø LOC; + LOC; lethargic; alert & awake | ||
| Injuries/Complaints | Neck pain; R skull fx; leg bruise | ||
| Care Plan (11%) | Labs | Basic trauma lab; tox screen | |
| Consults | Ortho; N Surg consult | ||
| Imaging Tests | Chest, c-spine; Xray; CXR; CT Head | ||
| Disposition | PICU; Neuro | ||
| Medications/Fluids | Bolus fluids; LR 28 | ||
| Other | Consider NAT; obs pl ambulate | ||
| Injury Type & Location (9%) | L LQ abrasion; multiple lacs; facial bruising | ||
| Task Completion Status (4%) | Deferred; Not done; In progress; N/A | ||
| Treatments & Procedures (3%) | IV/IO | Size/Location | R A/C – 20; 22g L hand; 16 ga |
| Meds & Fluids | Type/Rate/Dosage/Time | Start LR @ 65; 600 ml LR; NS @ 50; etom in; atropine → 15.30 | |
| Intubation | Tube Size & Location | 4 cuffed, 13 @ lips | |
| Chest Decompression | L needle decompression | ||
| Other (3%) | Notes to trauma office, unreadable | Bair hugger not available | |
| Laboratory Results (1%) | Dstick = 111; HH values: 50 over 30, 15 over 40, 16 over 48; AST/ALT – 117/91 | ||