Tertiary Survey
exp date isn't null, but text field is
UNIVERSITY OF MICHIGAN HEALTH SYSTEMS TRAUMA TERTIARY SURVEY
To be completed within 24 hours of admission
If the patient is unconscious, intoxicated, or sedated, the tertiary survey will be repeated once the patient regains consciousness
Substance Abuse Screening: □Negative (No Further Intervention Needed)
□Positive - Social Work Substance Abuse Consult Ordered: □YES □NO
Blood Acohol Level: ____ UTOX performed: □YES □NO
Subjective:_________________________________________________________________________
VS: T HR: RR: BP: O2Sat:_
|
GENERAL |
YES |
NO |
|
ABDOMEN |
YES |
NO |
|
Alert |
□ |
□ |
|
Lacerations/Abrasions |
□ |
□ |
|
Oriented |
□ |
□ |
|
Swelling/Ecchymosis |
□ |
□ |
|
GCS 15 |
□ |
□ |
|
Absent Bowel sounds |
□ |
□ |
|
HEENT |
|
|
|
Pain/Tenderness |
□ |
□ |
|
Pain/Tenderness |
□ |
□ |
|
Rigidity/Guarding |
□ |
□ |
|
Lacerations/Abrasions |
□ |
□ |
|
Distended |
□ |
□ |
|
Swelling/Ecchymosis |
□ |
□ |
|
Unstable Pelvis |
□ |
□ |
|
Numbness/Tingling |
□ |
□ |
|
Drains |
□ |
□ |
|
Malocclusion |
□ |
□ |
|
BACK |
|
|
|
Abnormal visual acuity |
□ |
□ |
|
Lacerations/Abrasions |
□ |
□ |
|
Contact lenses / Glasses |
□ |
□ |
|
Swelling/Ecchymosis |
□ |
□ |
|
Dentures |
□ |
□ |
|
Pain/Tenderness |
□ |
□ |
|
Abnormal hearing |
□ |
□ |
|
Step-offs |
□ |
□ |
|
NECK |
|
|
|
EXTREMITIES (UPPER) |
|
|
|
Cleared C-Spine |
□ |
□ |
|
Deformity |
□ |
□ |
|
Pain/Tenderness |
□ |
□ |
|
Lacerations/Abrasions |
□ |
□ |
|
CHEST |
|
|
|
Swelling/Ecchymosis |
□ |
□ |
|
Asymmetrical |
□ |
□ |
|
Pain/Tenderness |
□ |
□ |
|
Pain/Tenderness |
□ |
□ |
|
Absent Pulses |
□ |
□ |
|
Lacerations/Abrasions |
□ |
□ |
|
Extremity involved |
□Rt |
□Lt |
|
Swelling/Ecchymosis |
□ |
□ |
|
EXTREMITIES (LOWER) |
|
|
|
Air/Bony Crepitus |
□ |
□ |
|
Deformity |
□ |
□ |
|
Abnormal Heart sound
|
□ |
□ |
|
Lacerations/Abrasions |
□ |
□ |
|
Arrhythmia |
□ |
□ |
|
Swelling/Ecchymosis |
□ |
□ |
|
Unclear Breath sounds |
□ |
□ |
|
Pain/Tenderness |
□ |
□ |
|
Chest Tubes |
□ |
□ |
|
Pulses |
□ |
□ |
|
OTHER: |
|
|
|
Extremity involved |
□Rt |
□Lt |
Labs: Ca PT Other pertinent labs:
Mg INR
PO4 PTT
Operative, interventional Procedures: __________________________________________________ ___________________________________________________________________________________
Radiology: (“D” if study done, “F”: final report, “P” if study pending)
CT scan: Head: ____ C-Spine: ____ Face: ____ Chest: ____ A/P: ____ other:
X-ray: Chest: ____ Pelvis: ____ other:
Identified Injuries: (list all injuries and OR/IR Findings)
|
Injury type |
Consultant |
Plan for specific injury |
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IS THE WORK-UP FINAL? YES: ____ NO: ____
Studies to Follow: ____________________________________________________________
____________________________________________________________________________
New findings / Unresolved:_____________________________________________________
____________________________________________________________________________
Post survey add-on Plan: ______________________________________________________
____________________________________________________________________________
Signature / Title Pager Date Time