A trauma assessment is the trauma team’s record of a major injury: the paramedics’ handover, the primary survey in ATLS order, adjuncts such as eFAST, the resuscitation, the secondary survey, and the times that show how fast each step happened. Copy the free trauma note template, see a high-speed car crash taken to the operating room on a massive transfusion and an older adult on apixaban with a subdural and rib fractures, and check what goes in each part.
Blank trauma assessment template
FreeTRAUMA ASSESSMENT Patient: [Name or trauma alias, age, sex] Record number and date: [Chart or record number, date] Clock used: [Wall clock, monitor, or recorder's sheet] ACTIVATION AND ARRIVAL Time of injury: [Time, stated or estimated, and where it came from] Trauma team activation: [Level, time paged, and the criteria met] Arrival: [Time and mode: ground ambulance, helicopter, private vehicle, or transfer from another hospital] Team: [Leader with time at the bedside; airway, procedures, nursing, recorder, and others, with arrival times] PREHOSPITAL REPORT Handover: [Who gave it, the time, and the format, such as MIST] Mechanism: [What happened: speed, restraint, airbags, intrusion, ejection, height of a fall, weapon, extrication time] Injuries found or suspected: [What the crew found] Signs: [First and last prehospital vital signs and GCS with E, V, M, each with its time] Treatment given: [Airway, oxygen, access, fluids, blood, tranexamic acid with time, tourniquet with time applied, splints, pain relief] PRIMARY SURVEY Catastrophic hemorrhage: [External bleeding, and how it was stopped: pressure, packing, or tourniquet with time] Airway with cervical spine protection: [Patent, at risk, or secured; device, size, and how it was confirmed; collar or manual stabilization] Breathing: [Rate, SpO2 and oxygen, chest movement, breath sounds, trachea, chest wall, and any decompression or chest tube with time] Circulation: [Heart rate, blood pressure, skin and capillary refill, bleeding sources, pelvic binder, and access] Disability: [GCS as E, V, M and total, pupil size and reaction, limb movement, glucose] Exposure: [Fully exposed, temperature, and warming measures] Reassessed: [Times the survey was repeated, and what changed] ADJUNCTS eFAST: [Time, operator, and each view: right upper quadrant, left upper quadrant, pelvis, pericardium, both lungs] Chest and pelvis X-rays: [Times and findings, or skipped and why] Monitoring and tubes: [ECG rhythm, end-tidal CO2, urinary catheter, gastric tube] Bloods sent: [Group and crossmatch, CBC, coagulation, fibrinogen, blood gas with lactate and base deficit, ionized calcium, pregnancy test, alcohol] RESUSCITATION Massive transfusion protocol: [Activated or not, the time, and the trigger] Blood products: [Red cells, plasma, platelets, and fibrinogen or cryoprecipitate: units and times] Tranexamic acid: [Dose, start time, minutes since injury, and the second dose] Calcium and warming: [Ionized calcium, the dose given and time, and warming measures] Blood pressure target: [The target and the reason] Anticoagulant reversal: [Drug, last dose time, reversal agent, dose, and time given] Response: [Vital signs after each step: responder, transient responder, or non-responder] SECONDARY SURVEY Head, face, and neck: [Scalp, skull, eyes, ears, nose, facial bones, mouth; collar, midline tenderness, trachea] Chest and abdomen: [Chest wall, breath and heart sounds; bruising, tenderness, distension, seatbelt sign] Pelvis and perineum: [Bruising, blood at the urethral meatus, perineal wounds] Spine and back: [Log roll with in-line stabilization: bruising, step-off, midline tenderness] Limbs: [Deformity, wounds, pulses, sensation, movement, compartments] Neurological: [Repeat GCS as E, V, M, pupils, focal deficits] Deferred: [What was not examined, why, and who will finish it] AMPLE HISTORY Allergies: [Drug and other allergies, with the reaction] Medications: [Current medicines, with any anticoagulant or antiplatelet and the time of the last dose] Past history: [Conditions, surgery, and pregnancy status when relevant] Last meal: [Time and what] Events: [What led to the injury, and anything before it, such as a faint, seizure, or chest pain] Source: [Patient, family, paramedics, or records] RESULTS AND CONSULTS Labs: [Key results with the time drawn] CT: [Studies, time scanned, and findings, marked preliminary or final, with who read them] Other imaging: [Limb X-rays, angiography, or none] Consultations: [Service, consultant's name, time called, time they replied or arrived, and their advice] INJURY LIST AND PLAN Injuries: [Each injury, confirmed or suspected, one per line] Plan: [Operation, interventional radiology, admission, observation, repeat imaging, or transfer, for each injury] Tetanus: [Given, up to date, or not needed] Tertiary survey: [When it is due, and who will do it] DISPOSITION AND TIMES Disposition: [Operating room, interventional radiology, ICU, ward, transfer, or home, with the time] Family and goals of care: [Who was told, by whom, and when; goals of care confirmed, when relevant] Key times: [Injury, arrival, activation, first blood, CT, decisions, and departure from the trauma bay] Signed: [Team leader name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Trauma center resuscitation bay, highest-level activation, to the operating room 23 minutes after arrival
Time of injury 22:15, estimated from the 911 call at 22:17. Highest-level trauma team activation at 22:52 on the paramedics’ pre-alert: systolic BP under 90 after a high-speed crash. Blood bank told at 22:55. Arrived 23:08 by ground ambulance. 34-year-old man. Team leader: Dr. Rachel Okafor, trauma surgeon, at the bedside from 23:00. Airway: Dr. Mark Ellis, anesthesia. Procedures: emergency medicine resident. Two trauma nurses, one on the rapid infuser. Recorder: Jo Patel, RN, from the wall clock. Handover at 23:08 by Paramedic Chris Molina, in MIST order, team hands off. Mechanism: belted driver; car left a wet highway and hit a tree head-on at about 100 km/h (60 mph); airbags deployed, steering wheel bent, dashboard pushed into the driver’s footwell; 20 minutes to free him. Injuries: seatbelt bruise across the lower abdomen, abdominal pain, tender left lower ribs, deformed right forearm. Signs: 22:31, HR 118, BP 102/64, RR 22, SpO2 96% on room air, GCS 15: E4, V5, M6. 23:02, HR 130, BP 84/52, SpO2 95% on 15 L by mask, GCS 15. Treatment: 16-gauge IV in each arm after extrication; tranexamic acid 1 g IV over 10 minutes from 22:48; fentanyl 50 mcg IV at 22:50; saline 250 mL at 22:58 for a weak radial pulse; collar on; right forearm splinted.
23:09 to 23:15. Catastrophic hemorrhage: no external bleeding. Airway: talking in full sentences; patent. Collar checked under manual in-line stabilization and kept on. Breathing: RR 26, SpO2 96% on 15 L by mask; trachea midline; chest rising equally; breath sounds equal; tender over the left lower ribs, no crepitus or open wound. Circulation: HR 132, BP 86/54; pale and cool, capillary refill 4 seconds; abdomen distended and tender. Pelvic binder placed at the greater trochanters at 23:11 until the X-ray; pelvis not sprung. Both prehospital lines working; rapid infuser attached. Disability: GCS 15: E4, V5, M6. Pupils 4 mm, equal and reactive. Moves all four limbs. Glucose 8.2 mmol/L (148 mg/dL). Exposure: fully undressed; temperature 35.8 °C (96.4 °F); warmed blankets, forced-air warming, all blood through a warmer.
eFAST at 23:12 by Dr. Okafor: free fluid in the right upper quadrant, the left upper quadrant, and behind the bladder; no pericardial effusion; lung sliding on both sides. Chest X-ray at 23:14: fractures of the left 9th and 10th ribs; no pneumothorax or hemothorax; mediastinum not widened. Pelvis X-ray at 23:15: no fracture; binder removed at 23:17. Monitor: sinus tachycardia at 130. No blood at the urethral meatus; catheter left for the operating room. Bloods at 23:10: group and crossmatch, CBC, INR, fibrinogen, venous gas, ionized calcium, alcohol.
Massive transfusion protocol activated at 23:13: ABC score 3, for blunt injury 0, systolic 90 or under 1, heart rate 120 or over 1, positive FAST 1. Uncrossmatched group O red cells and thawed plasma, 1 to 1, through the rapid infuser from 23:15. By 23:30: 4 units of red cells, 4 units of plasma, and 1 adult dose of platelets. Tranexamic acid: first gram from 22:48, 33 minutes after injury; second gram as an infusion over 8 hours from 23:18. Ionized calcium 0.98 mmol/L (3.9 mg/dL) at 23:16; calcium gluconate 3 g IV at 23:19. Target systolic 80 to 90 mmHg until the bleeding is controlled: GCS 15, no sign of head injury. No crystalloid in the bay. Response: 23:20, after 2 units of each, BP 92/58, HR 118; 23:28, BP 84/52, HR 126. Transient responder.
Limited survey at 23:21 while blood ran; the full survey deferred until after surgery. Head and face: no scalp wound or swelling; face stable; no blood from the ears or nose. Neck: collar on; trachea midline. Abdomen: distended, tender throughout with guarding; seatbelt bruise 3 cm wide across the lower abdomen. Pelvis and perineum: no bruising. Log roll at 23:23 with in-line stabilization: no bruising, step-off, or midline tenderness from neck to sacrum. Right forearm: closed, angulated deformity midway along the forearm; radial pulse present; sensation and finger movement normal; splint kept. Other limbs normal. AMPLE, from him: no allergies; no medicines; no past illness or surgery; last ate at 19:00; driving home from work, the car slid on the wet road, no faint or chest pain before it. Tetanus booster 4 years ago.
Venous gas at 23:16: pH 7.24, lactate 5.8 mmol/L, base deficit 9. Hemoglobin 10.9 g/dL (109 g/L), platelets 214, INR 1.4, fibrinogen 1.8 g/L (180 mg/dL). Alcohol not detected. No CT: too unstable to leave the bay. Anesthesia, Dr. Ellis, at the bedside from 23:12. Operating room called at 23:14. Orthopedics, Dr. Sara Kim, called at 23:25 for the forearm: will see him after surgery.
Hemorrhagic shock from bleeding in the abdomen, likely spleen or liver; transient responder. Left 9th and 10th rib fractures, over the spleen. Seatbelt sign: suspected bowel or mesenteric injury, and a possible lumbar flexion-distraction fracture. Right forearm deformity, likely a closed fracture of both bones. Decision at 23:14: laparotomy, for hypotension with a positive FAST. Continue the transfusion protocol in the operating room, guided by blood gases and coagulation results. After surgery, if stable: CT head, cervical spine, chest, abdomen, and pelvis, with thoracic and lumbar spine reformats for the seatbelt sign, and forearm X-rays. Collar stays on until then. Tetanus up to date. Tertiary survey within 24 hours, by the trauma team, and again once he is awake.
To the operating room at 23:31 with Dr. Okafor and Dr. Ellis, red cells and plasma running. His wife, Laura, called by the trauma social worker at 23:24; on her way, and Dr. Okafor will update her after surgery. Key times: injury 22:15; tranexamic acid 22:48; arrival 23:08; positive eFAST 23:12; transfusion protocol 23:13; decision to operate 23:14; first blood 23:15; left the bay 23:31, 23 minutes after arrival.
Trauma center, second-tier activation, reversal in the bay, admitted to the trauma service
Time of injury about 14:30: her son found her at the bottom of the stairs at 15:05, and she had been on the floor up to 35 minutes. Second-tier trauma team activation at 15:40 on the pre-alert: age over 65, on an anticoagulant, with a head strike. Arrived 15:52 by ambulance with her son. 79-year-old woman. Team leader: Dr. Tom Rivera, emergency physician. Trauma surgeon, Dr. Helen Park, from 16:05. Recorder: Mia Santos, RN. Handover at 15:52 by Paramedic Jordan Reyes, in MIST order. Mechanism: fall down 12 carpeted stairs at home; found lying on her right side at the bottom; a laundry basket beside her. Injuries: swelling at the back of the head on the left; pain in the right side of the chest; no limb deformity. Signs: 15:12, HR 98 irregular, BP 172/94, RR 22, SpO2 91% on room air, GCS 14: E4, V4, M6. 15:45, HR 94, BP 166/90, SpO2 95% on 2 L by nasal prongs, GCS 14. Treatment: collar; oxygen 2 L; 18-gauge IV; fentanyl 25 mcg IV at 15:20. Apixaban in her pill organizer, brought along.
15:53 to 15:58. Catastrophic hemorrhage: none. Airway: talking; patent; collar on. Breathing: RR 22, shallow, guarding the right side; SpO2 95% on 2 L; trachea midline; breath sounds equal; tender over the right lateral chest with crepitus; no paradoxical movement. Circulation: HR 94, irregularly irregular; BP 164/88; warm, capillary refill 2 seconds; no external bleeding; abdomen soft; pelvis not tender, no binder. Disability: GCS 14: E4, V4, M6; confused about the day and why she is here, repeats questions. Her son says she is usually sharp and lives alone. Pupils 3 mm, equal and reactive. Moves all limbs equally. Glucose 7.1 mmol/L (128 mg/dL). Exposure: temperature 36.0 °C (96.8 °F); warmed blankets. Skin over the right hip intact after the time on the floor.
eFAST at 15:58: no free fluid in any abdominal view; no pericardial effusion; lung sliding on both sides. Chest X-ray at 16:02: displaced fractures of the right 6th and 7th ribs; no pneumothorax or effusion. Pelvis X-ray skipped: stable, and CT of the pelvis to follow. ECG at 16:00: atrial fibrillation at 92, no acute ST changes. Bloods at 16:00: CBC, INR, creatinine, group and screen, CK, high-sensitivity troponin, and an anti-Xa level calibrated for apixaban.
No blood products: blood pressure and perfusion normal. Anticoagulant: apixaban 5 mg twice daily for atrial fibrillation, last dose at 08:00, by her pill organizer and her son. CT showed a subdural, read by phone at 16:40; 4-factor prothrombin complex concentrate 2,000 units IV at 16:58, the fixed dose in the hospital’s factor Xa inhibitor protocol, 18 minutes after the read. Reversal not delayed for the anti-Xa level. Apixaban held. Pain: fentanyl 25 mcg IV at 16:05; acetaminophen 1 g IV at 16:20; no anti-inflammatories. Systolic target under 160 mmHg, per neurosurgery: 152/82 at 17:30 once her pain eased, with no antihypertensive needed.
Full survey at 16:08. Head and face: 4 cm boggy swelling over the left occiput, skin intact; no bruising behind the ears or around the eyes; no fluid from the nose or ears; face not tender. Neck: collar on; midline tenderness can’t be judged reliably while she is confused. Chest: bruised and tender over the right lateral ribs, with crepitus; no flail segment. Abdomen: soft, not tender, no bruising. Pelvis and perineum: not tender; no bruising. Log roll with in-line stabilization: bruise over the right hip; no step-off. Limbs: bruised right elbow with full movement; both hips move freely without pain; pulses normal. Neurological: GCS 14: E4, V4, M6, unchanged; pupils equal; no focal weakness; speech fluent. AMPLE, from her son and her pharmacy list, as she can’t recall the fall: penicillin allergy, hives; apixaban as above, metoprolol 25 mg twice daily, amlodipine 5 mg daily; atrial fibrillation, high blood pressure, osteoporosis; lunch at about 12:30; she was carrying laundry downstairs, and no one knows whether she fainted first. Clinical Frailty Scale 3 by her son’s account: independent, walks daily, conditions controlled.
CT at 16:15, preliminary read 16:40, final 17:05. Head: acute right frontoparietal subdural hematoma, 5 mm thick, no midline shift; left occipital scalp swelling; no skull fracture. Cervical spine: no fracture; degenerative changes. Chest, abdomen, and pelvis with contrast: fractures of the right 5th to 8th ribs, each broken in one place; small right lung contusion; no pneumothorax, hemothorax, abdominal injury, or pelvic fracture. Labs: hemoglobin 12.6 g/dL (126 g/L), platelets 188, INR 1.2, creatinine 0.9 mg/dL (80 µmol/L), CK 410 U/L, troponin below the assay’s 99th percentile; anti-Xa apixaban level 142 ng/mL, drawn 16:00, back at 18:10. Neurosurgery, Dr. Ana Ruiz, called 16:45, replied 16:55: no surgery; reverse; neuro checks every hour; repeat CT head at 6 hours, or sooner if her GCS falls; systolic under 160; anticoagulant held until they review. Acute pain service called 17:15 to assess her for a serratus anterior plane block. Geriatric medicine asked to see her tomorrow.
Small acute right subdural hematoma on apixaban, reversed. Right 5th to 8th rib fractures with a lung contusion. Left occipital scalp hematoma. New confusion: brain injury, delirium, or both. Fall of unknown cause. Plan: admit to the trauma service in the step-down unit, for hourly neuro checks and 4 rib fractures at 79. Repeat CT head at 22:15. Scheduled acetaminophen; the plane block if the acute pain service agrees; low-dose opioid only for breakthrough pain. Incentive spirometer every hour while awake; 750 mL at baseline. Collar removed at 17:10 after the final read, under the hospital’s protocol for patients who can’t yet be examined reliably. Cause of the fall: telemetry, and lying and standing blood pressure once safe to stand. Delirium prevention: glasses, hearing aids, her son at the bedside, and sleep at night. Tetanus not needed: no wounds. Tertiary survey within 24 hours, and again once her GCS is 15, including her hands and feet.
Admitted to the trauma service, step-down unit, at 18:20. Goals of care: full treatment, confirmed with her and her son. Her son was present for the plan; Dr. Park explained the subdural, the reversal, and the repeat scan. Neuro checks at 17:00 and 18:00: GCS 14: E4, V4, M6, pupils equal. Key times: injury about 14:30; found 15:05; arrival 15:52; CT 16:15; preliminary read 16:40; reversal 16:58, 66 minutes after arrival; admitted 18:20.
When the injury happened, how the team was called, and the paramedics’ handover, often given in MIST order: mechanism, injuries, signs, and treatment. The team listens, hands off, unless something can’t wait.
Avoid: Leaving out the time of injury. Tranexamic acid, transfusion decisions, and the trauma review all count from it.
Most trauma teams follow ATLS, the American College of Surgeons’ trauma course: find and treat what kills first, in order, before moving on. Many systems now put catastrophic external bleeding first, written xABCDE.
Avoid: Writing the survey once, as if nothing changed. Repeat it after each intervention and whenever the patient gets worse, and record the time of each pass.
The bedside tests done during or right after the primary survey, without leaving the bay.
Avoid: Taking a negative FAST as reassurance in a hypotensive patient. FAST misses retroperitoneal bleeding, such as from a pelvic fracture, and some bowel injuries; write each view, and repeat it if the patient changes.
What was given to restore circulation and stop bleeding, each with its time, and how the patient responded.
Avoid: Liters of crystalloid with no reason. In hemorrhage, blood comes first; if saline was given, write how much and why.
The head-to-toe exam and a short history, once the primary survey is done and the patient is stable enough. AMPLE is the history trauma teams take in the bay.
Avoid: “Secondary survey deferred” with nothing after it. Name what wasn’t examined, and plan the rest after surgery or at the tertiary survey.
The labs and imaging that defined the injuries, and the services called, with times.
Avoid: Acting on a preliminary read without saying so. Mark which reads were preliminary, and add the final report when it changes anything.
Every injury found or suspected, one per line, each with its plan. The tertiary survey is planned here.
Avoid: Listing only the obvious injuries. Missed injuries are often in the hands, feet, and spine; list the suspected ones too, and recheck them at the tertiary survey.
Where the patient went from the trauma bay, who was told, and the times a trauma review reads first.
Avoid: Times scattered through the note. Gather the key ones in one line at the end, so the review doesn’t have to rebuild the timeline.
GCS 14 could mean confused speech or a weaker motor response, and they mean different things. Write E, V, and M, check they add up, and write NT for a part that can’t be tested.
Its benefit depends on starting within 3 hours of injury. Record the time of injury, where it came from, and the start time of each dose.
When an unstable patient goes straight to surgery, write what wasn’t examined and who will finish it. Plan the tertiary survey before the patient leaves the bay.
Older adults on blood thinners can look well with a bleed. Ask early, write the drug and the time of the last dose, and record when reversal was given.
A trauma review reads the minutes: injury to tranexamic acid, arrival to first blood, arrival to CT or the operating room. Use one clock, the same as the recorder’s.
Vero Scribe writes the trauma assessment in your template from your dictation after the resuscitation, or from the conversation with the patient, with their consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The time of injury and the activation, the paramedics’ handover, the primary survey in order, adjuncts such as eFAST and chest and pelvis X-rays, the resuscitation with blood products and tranexamic acid times, the secondary survey and AMPLE history, results and consults, an injury list with a plan for each, the disposition, and the key times. A trauma note and a trauma assessment are usually the same document.
The primary survey finds and treats what threatens life first: catastrophic bleeding, airway with cervical spine protection, breathing, circulation, disability, and exposure. The secondary survey is the head-to-toe exam and AMPLE history once the patient is stable enough. The tertiary survey repeats the full exam and reviews all imaging, usually within 24 hours and again once the patient is awake, to catch injuries missed in the first hours. The first two follow ATLS, the American College of Surgeons’ trauma course.
An ED note records one visit for a complaint, built around a history, decision rules, and a disposition. A trauma assessment follows the surveys: what threatened life, what was done about it and when, then the full exam and imaging. The paramedics write their own patient care report, and a cardiac arrest gets its own resuscitation record. Many EDs use an ED note for minor injuries and a trauma assessment when the trauma team is activated.
Write each part and the total, such as GCS 14: E4, V4, M6, and check they add up. Give the time, and note anything that could lower it, such as sedation, alcohol, or swollen eyes. If a part can’t be tested, write NT, or VT for verbal when the patient is intubated, and give the parts without a total. Record pupil size and reaction beside it, and repeat both at each reassessment.
Yes. Copy it, or download it as a Word or text file. No account needed.
One ED visit: triage, a timed ED course, results, decision rules, disposition, return precautions, and handoff.
Trauma assessments and ED notes, drafted for your review.
Common codes for the injuries on your list.
Score eye, verbal, and motor responses, and record them the same way each time.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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