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TRAUMA HISTORY AND PHYSICAL EXAMINATION Date:Time:He of Present Illness (HP)Type of Trauma Melted? YesNoTiming/DurationAirbagPedestrianMCCAssaultFallBurnElectricalGSWStabOther: Helmet:EjectionYesNoChemicalCrushBiologicalEyesENTLoss
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How to fill out trauma history and physical
How to fill out trauma history and physical
01
Step 1: Begin by gathering all the necessary information about the patient's medical history, including any previous traumas or accidents they have experienced.
02
Step 2: Collect information about the patient's current physical condition, including vital signs, general appearance, and any noticeable injuries or abnormalities.
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Step 3: Begin documenting the trauma history by asking the patient about any previous accidents, surgeries, or injuries they have sustained in the past.
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Step 4: Ensure to record detailed information about each trauma event, including the date, location, nature of the injury, and any treatment received.
05
Step 5: Proceed with the physical examination, carefully assessing the patient's body systems, checking for any tenderness, swelling, or deformities that might indicate trauma.
06
Step 6: Perform necessary diagnostic tests, such as X-rays or blood tests, to further evaluate the extent of any injuries or underlying conditions.
07
Step 7: Finally, summarize all the gathered information and findings in a clear and organized manner in the trauma history and physical form.
Who needs trauma history and physical?
01
Trauma history and physical is usually required for patients who have sustained previous injuries, undergone surgeries, or have a history of accidents or trauma.
02
This form is commonly used in emergency departments, primary care settings, and when evaluating patients for surgeries or specialized treatments.
03
Doctors, nurses, and other healthcare professionals utilize trauma history and physical to assess the patient's overall health, identify potential risks, and guide further treatment decisions.
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What is trauma history and physical?
Trauma history and physical is a detailed record of a person's past injuries, accidents, surgeries, and medical history.
Who is required to file trauma history and physical?
Healthcare providers, such as doctors or nurses, are required to file trauma history and physical for their patients.
How to fill out trauma history and physical?
Trauma history and physical can be filled out by providing detailed information about the patient's medical history, surgeries, and previous injuries.
What is the purpose of trauma history and physical?
The purpose of trauma history and physical is to provide healthcare providers with a comprehensive understanding of a patient's medical background to ensure appropriate treatment.
What information must be reported on trauma history and physical?
Information such as previous injuries, surgeries, medical conditions, and medications must be reported on trauma history and physical.
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