Emergency Trauma Surgery Documentation Template
Patient Information
Full Name
Age
Gender
Male
Female
Other
MRN
Date & Time of Admission
Date
Time
Referring Facility / Physician
Mechanism of Injury
Pre-hospital Care
Initial Assessment
Airway
Breathing
Circulation
Disability (GCS)
Exposure / Environment
Vital Signs
Blood Pressure
Heart Rate
Respiratory Rate
Temperature
O
2
Saturation
Physical Examination Findings
Imaging / Labs
Diagnosis
Operative Findings
Procedures Performed
Post-operative Plan
Consults / Referrals
Attending Surgeon