This is a [age] year old [gender] who presents on [date] as a [p1/p2/consult] after [mechanism].
Trauma bay course remarkable for [course].
Injuries (by system)
Head: []
Spine: []
Chest: []
Intraperitoneal: []
Retroperitoneal: []
MSK []
Consults:
[]
# Neuro
GCS in trauma bay: []
GCS on arrival: []
Sedation: gtt: [] / sch: [] / prns: []
# Pain: gtt: [] / sch: [] / prns: []
# Cardiovascular
MAP: []
HR: []
Pressors: []
Trops: []
EKG: []
ECHO: []
# Respiratory
Vent settings: []
ABG: []
CXR: []
# GI/Nutrition
Diet: []
NGT/OGT: []
Bowel reg: Miralax BID
# Renal
Fluids in trauma bay: []
Monitor UOP
Lab schedule: []
Foley: []
Lactate: []
BMP: []
Mg/Phos: []
Fluid status: []
IVF: []
# Hematology
Tranfusions in trauma bay: []
Hgb/Hct: []
Platelets: []
# Infectious
Temp: []
WBC: []
Antibiotics: []
# Endocrine
BG on arrival: []
Insulin: []
POC BG Schedule: []
# MSK
PT/OT
# PPx
DVT: []
GI: []
# Access
[]
# Disposition
TICU
Service: TICU
Author: Garrett Skinner