Secondary Survey: Trauma Assessment and Documentation Checklist

A secondary survey is the systematic history and detailed examination used to identify additional injuries after the primary survey and management of immediate life threats. It combines the injury story, head-to-toe findings and observations with a plan for further assessment. Monitoring continues throughout; a new life threat takes priority over finishing the checklist. WHO and ICRC: Basic Emergency Care

This guide focuses on adult trauma assessment and documentation. Read the examination checklist, work through SS-01, or copy the blank record.

Sources checked: October 30, 2026.

Primary and secondary surveys have different jobs

The primary survey identifies and addresses immediate threats. The secondary survey provides a more detailed injury assessment once those priorities have been managed. It is not a one-way progression: if the patient deteriorates, return to the primary assessment. The Victorian State Trauma System makes that return explicit.

Be precise about the framework your team uses. The American College of Surgeons introduced xABCDE in ATLS 11 in 2025, adding attention to exsanguinating external hemorrhage before the familiar airway, breathing, circulation, disability and exposure sequence. That is a primary-survey framework; it does not turn the secondary survey into another acronym checklist. ACS ATLS 11 update

The Queensland Ambulance Service’s June 2026 procedure organizes secondary assessment around history, vital signs and physical examination. It applies to authorized QAS clinicians in the prehospital setting, with observations selected to match the presentation. QAS primary and secondary survey

For documentation, distinguish three separate statements: “the clinician assessed readiness to proceed,” “these areas were examined,” and “these findings were acted on.” A completed primary assessment does not prove the secondary examination occurred. A completed secondary examination does not prove that every investigation has been reported or reviewed.

AMPLE history: keep the source with the answer

The Victorian guidance uses AMPLE: allergies, medications, past medical history, last meal and events surrounding the injury. WHO’s SAMPLE also names signs and symptoms explicitly and uses last oral intake. These are memory aids for gathering information, not evidence that every answer is known. Attribute accounts to the patient, EMS, witnesses or a dated record. Victorian history guidance

• Allergies: retain the reported substance and reaction. “Patient cannot recall” differs from a completed negative history.
• Medications: record the source, known names and last doses, plus gaps needing confirmation. An old medicine list is not proof of current use.
• Past history: identify relevant conditions and treatment history; preserve uncertainty about immunization or other requested details.
• Last oral intake: record what is known and the reported time. An estimated time stays an estimate.
• Events: separate the mechanism reported by EMS from what the patient remembers. Include symptoms preceding the event when reported rather than assuming the injury explains everything.

For example, “EMS reports a helmeted bicycle fall; patient remembers hitting a pothole but cannot estimate speed” preserves both accounts. “Low-speed fall” adds certainty that neither source supplies. If a companion later supplies a different account, add the new source and time; do not silently replace the earlier history. The collateral-information guide explains that attribution problem in more detail.

Adult secondary survey checklist

Use these region prompts with the service’s examination procedure. Record findings, side, time and assessment limits, rather than marking an entire region “normal” from a partial look. The clinical prompts below summarize selected elements of the NSW adult secondary-survey guidance, published December 2023.

Scroll the table sideways on smaller screens.

Maintain warmth and privacy. Do not remove an existing pelvic binder to complete a row. Posterior examination requires an appropriate team and precautions; avoid a log roll when it could worsen an unstable pelvis. The linked NSW guidance provides the clinical context for these restrictions.

Record neurological findings and observations alongside the regional examination. QAS includes GCS and physiological measurements within its assessment procedure, as appropriate. A numerical result needs its named measure; observations need their actual time and units. Record the measurement context and trends in the encounter’s linked observation record.

An interrupted, declined or limited examination needs an explicit status. “Back not yet examined” is actionable when accompanied by a reason and owner. “Back normal” is a false finding if it was never examined. An assessment completed at 14:24 must not be backdated into a 14:12 entry merely to make the first note appear complete.

SS-01: a deferred examination with a completed follow-up

Fictional adult emergency-department case. Follow the history, timed findings and unfinished tasks from the source packet into the documentation excerpt.

Source packet

At 14:10, Dr. Rowan, the treating clinician, documents that the initial primary assessment and immediate management have been completed and directs continuation with the secondary survey. The primary-assessment findings and treatment are held in a separate record. Prescribed spinal precautions remain in place. Nurse Morgan records the following supplied information:

• History at 14:12: the patient reports falling from a bicycle after hitting a pothole at approximately 13:40. EMS reports the patient wore a helmet. The patient reports no known medicine allergies, takes a blood-pressure tablet but cannot name it, and last ate a sandwich at approximately noon. The patient cannot recall the last tetanus vaccination. Pharmacy verification has been requested; no reply has arrived.
• Examination at 14:14: Dr. Rowan identifies a 2 cm left-forehead abrasion and left-wrist swelling with tenderness. Both pupils are 3 mm and reactive to light. The patient is oriented and follows commands. These observations do not supply a complete GCS component record.
• Left hand at 14:16: Dr. Rowan records a palpable radial pulse, intact light-touch sensation in all fingers and active finger movement. Wrist movement is limited by reported pain. These are left-sided findings; the packet supplies no right-hand examination.
• Deferred area at 14:18: posterior examination has not occurred because the necessary staff for the prescribed assisted movement are not yet present. Dr. Rowan owns completion with the assisting team before transfer out of the assessment area. Morgan will confirm readiness with Rowan when staff arrive; if that checkpoint cannot be met, Rowan will review the transfer plan and hand over the unfinished examination explicitly.
• Follow-up at 14:24: with staff present and precautions maintained, Dr. Rowan examines the posterior surfaces and records a superficial abrasion over the left scapular area and no midline thoracic or lumbar tenderness on palpation. Other findings are not supplied.
• Outstanding at 14:28: a requested left-wrist radiograph has not yet been performed. Dr. Rowan retains responsibility for reviewing the result and recording the management decision before disposition. Morgan will check the request’s status at the team’s agreed 14:40 checkpoint, raising a delay to Rowan. Pharmacy verification remains assigned to Morgan before medication reconciliation is finalized.
• Immunization follow-up at 14:28: Dr. Rowan owns review of the unresolved tetanus history at the team’s agreed 14:40 checkpoint. If the history remains unconfirmed, Rowan will document the uncertainty and next steps before disposition. The packet supplies no prophylaxis decision or administration.

The fictional team agrees to these review checkpoints; a new clinical concern prompts immediate reassessment.

Finished secondary-survey excerpt

14:12 — Secondary survey following Dr. Rowan’s documented primary assessment and direction at 14:10; prescribed spinal precautions maintained. Patient reports bicycle fall after pothole at approximately 13:40; helmet use reported by EMS. Patient reports no known medicine allergies. Unnamed blood-pressure tablet requires verification; pharmacy response pending. Last meal approximately noon; last tetanus vaccination unknown.

14:14–14:16 — Dr. Rowan’s findings: 2 cm left-forehead abrasion; pupils 3 mm bilaterally and reactive. Patient oriented and follows commands. Left wrist swollen and tender; movement limited by reported pain. Left radial pulse palpable, finger light-touch sensation intact and active finger movement present.

14:18 — Posterior examination deferred pending staff for assisted movement under prescribed precautions. Dr. Rowan owns completion before transfer from assessment area; Morgan to confirm with Rowan when staff arrive. If completion cannot precede transfer, Rowan to review transfer plan and explicitly hand over the outstanding examination.

14:24 — Posterior examination completed by Dr. Rowan with assisting staff and precautions maintained: superficial left-scapular abrasion; no midline thoracic or lumbar tenderness on palpation. Deferred posterior examination closed at this time.

14:28 — Wrist radiograph requested, not yet performed. Rowan owns result review and management decision before disposition. Morgan to check request status at agreed 14:40 checkpoint and raise delay to Rowan. Medicine identity remains unresolved; Morgan owns pharmacy follow-up for medication reconciliation. Tetanus history remains unconfirmed. Rowan to review it at the agreed 14:40 checkpoint; if still unknown, Rowan to document the uncertainty and next steps before disposition. No prophylaxis decision or administration documented in this excerpt. Entry recorded by Morgan; examination findings attributed to Rowan.

What the record preserves

The final excerpt demonstrates completion of one previously deferred task without declaring the entire secondary survey complete. The posterior findings belong to 14:24, while the left-hand findings belong to 14:16. Neither set establishes an examination of all the other regions in the checklist.

The note also distinguishes a patient's report from a verified medication list. It does not name the tablet, supply a vaccination date or assign a fracture diagnosis. A requested radiograph stays requested. Medication verification, result review and tetanus-history follow-up retain their owners after the posterior examination closes. Rowan’s planned history review does not establish that the history was verified or that prophylaxis was decided on or administered.

Practice: review a compressed draft

Compare this draft with the packet: “14:18: Secondary survey normal apart from wrist fracture and forehead abrasion. GCS 15. Back nontender. Medicines reconciled. X-ray reviewed.” Identify unsupported statements, timing errors and missing tasks before opening the answer.

Reveal the SS-01 record check

• “Secondary survey normal” exceeds the supplied regional findings and conceals a deferred examination.
• “Wrist fracture” adds a diagnosis; swelling and tenderness are the supplied findings.
• “GCS 15” adds a scored assessment without all component findings. Retain the actual neurological observations.
• “Back nontender” at 14:18 imports a later, more specific examination into the wrong time.
• “Medicines reconciled” erases the unidentified tablet and pending verification.
• “X-ray reviewed” converts a request into a completed test and review.

Replace the draft with the timed excerpt above. Keep Rowan’s outstanding result-review responsibility, Morgan’s pharmacy follow-up and Rowan’s tetanus-history review at the agreed 14:40 checkpoint. If that history remains unknown, preserve Rowan’s responsibility to document the uncertainty and next steps before disposition. Missing ownership would still matter even after every unsupported clinical statement was removed.

SS-02: deterioration interrupts the survey

Fictional documentation scenario. At 16:05, during a secondary examination, the patient reports new difficulty breathing. Nurse Chen observes increased breathing effort and immediately alerts the bedside trauma lead, Dr. Vale. Vale stops the secondary survey and begins primary reassessment at 16:05. The abdomen, pelvis and posterior surfaces have not yet been examined. The team's detailed reassessment, interventions and results belong in the linked resuscitation record.

At 16:07, Vale confirms responsibility for the ongoing reassessment and subsequent decision about further examination. The receiving resuscitation nurse, Ellis, accepts the monitoring handoff, including the unexamined areas, at 16:08. No decision to resume the secondary survey has been supplied.

16:05 — Secondary survey interrupted: patient reports new difficulty breathing; increased breathing effort observed by Chen. Dr. Vale alerted at bedside, stopped secondary examination and began primary reassessment. See linked resuscitation record for findings, interventions and response. Abdomen, pelvis and posterior surfaces not yet examined.

16:08 — Ellis accepted monitoring handoff. Dr. Vale retains reassessment and further-examination decision; secondary-survey completion remains outstanding. Unexamined areas communicated to both Vale and Ellis. No resumption documented in this entry.

WHO’s trauma teaching directs clinicians back to the primary survey when a primary-survey problem emerges. The documentation lesson is equally concrete: an interruption creates unfinished work, not a negative examination. Do not fill the remaining checkboxes while the team is responding to a new threat. A short handoff can use the service’s structure; the MIST report examples show how to retain changing observations and actual treatment status.

Copyable secondary survey documentation template

Copy the blank record into the organization’s clinical documentation system, using its protocol and headings. Record actual findings, interruptions, reassessments and accepted handoffs.

Keep any observation chart, resuscitation record and investigation list linked to the same encounter. If an EHR stores the examination and pending tasks separately, verify both destinations after saving.

From examination to an accepted handoff

NICE NG39 recommends a designated recorder for contemporaneous trauma-team findings and interventions, a team-leader completeness check, and documented structured handover. Documentation, images and reports should accompany transfers. These are UK major-trauma recommendations; local role assignments and transfer systems determine how a service implements them. NICE documentation and handover recommendations

For a practical completion check, connect each open item to a named person and a specific next event. “Await imaging” does not say who will notice a missing report. “Rowan to review the wrist result before disposition; Morgan to check request status at 14:40 and raise delay” states two different responsibilities. It still does not establish that the image was obtained.

At a change of team, communicate the incomplete examination, pending results and medication uncertainty along with the findings. Record who accepted each responsibility. If the destination cannot perform an outstanding assessment or review, that is a transfer-planning problem to resolve, not a field to mark complete. The SBAR handoff examples distinguish making a request from the receiver accepting it.

When an examination later becomes possible, add its new findings and time. When an earlier entry was wrong, use the record’s correction process and preserve the earlier information according to organizational policy. The DCHART documentation examples illustrate how a corrected narrative must stay consistent with structured observations.

Secondary survey quality checklist

Before authenticating the record, compare it with the actual assessment rather than checking whether every box contains text:

1. Identity and timing: patient, encounter, examination times, examiner and recorder are identifiable.
2. History: source and uncertainty remain attached to medication, allergy and mechanism accounts.
3. Findings: side, region and examination method are specific enough to interpret; no unperformed examination has become “normal.”
4. Precautions and limits: retained precautions, deferred regions and reasons remain visible.
5. Change: new symptoms, interruptions and repeat findings have their own times and actual responses.
6. Investigations: ordered, performed, available and reviewed are separate states.
7. Open work: a named owner, agreed checkpoint and response to delay accompany each unresolved item.
8. Saved destination: the clinical note, observation fields and handoff agree after saving, and the receiving clinician has accepted outstanding responsibilities.

For help preparing a clinical note draft, explore Vero’s clinical note generation workflow. Review the draft against the source findings, correct it and confirm the saved record before completing the documentation.

The useful endpoint is a record another clinician can act on. In SS-01, one deferred examination closes while imaging, medication and immunization questions stay open with named owners. In SS-02, the survey stays incomplete because urgent reassessment takes priority. Both records are more informative than a completed checklist that obscures what actually happened.