Module 1 – Lesson 4: Self-Assessment Question

Question

Review the following emergency room report summary and identify the salient information that should have been taken out of the original report. Rewrite the report with the correct information included.

You should not include information about liability issues; that responsibility falls on the patient’s attorney. The summary should identify how the client was injured (the general conditions of the accident, type of collision, degree of trauma incurred) and the acute treatment needed (all tests/procedures performed). Aim to reduce the amount of information to what is needed to developing a thorough plan.

Not all reports have the same amount of detail, and all will have a different format. The following information should be listed in the summary, if it is given in the medical documentation:

  • the client’s race/ethnicity;
  • the mode of arrival (helicopter/ambulance, etc.);
  • how the injury occurred (accident, burn, fall);
  • the nature of the injury (head injury, spinal cord injury, amputation, burn);
  • the chief complaint on admission;
  • loss of conscious if any time unconscious;
  • Glasgow coma scale score (ranges from 1-15);
  • emergent procedure (trachestomy, intubation);
  • X-Ray, CT scan, lab results;
  • medications administered (response to medication and medications prescribed at discharge);
  • behavioral status (agitated, flat affect, unresponsive);
  • examination findings;
  • diagnostic impression (usually given at the end of the report upon discharge);
  • discharge instructions (if listed).

Emergency Room Report Summary

Bobby’s address is 2525 River Road., Tampa, FL. He is a 25-year-old Hispanic male who sustained a traumatic amputation of both legs on 5/5/05. He was the passenger in a motor vehicle at the time of injury. Bobby was knocked unconscious for about two minutes before the paramedics arrived but came to when they got there.

The paramedics reported that he was blabbering nonsense words, did not know where he was, and seemed confused. When the paramedics asked him to touch his nose or hold up a few fingers, Bobby was able to do as requested. However, after a short time, his attention seemed to fade. Bobby was vomiting and was not expressing much emotion or concern. The paramedics called for assistance, and after a brief wait, a helicopter flew Bobby to the Tampa General Emergency Room.

The physician completed a general physical and asked questions regarding Bobby’s general condition.

Bobby’s mother was called. When the results from the CT came back, they were negative. Bobby requested a drink of water and crackers to settle his stomach. He then underwent bilateral amputation of both of his legs as they were badly damaged during the car accident. There were no complications following this surgery. After his 13- day hospital stay, Bobby was released to a Rehabilitation Center in Tampa with a discharge diagnosis of bilateral above knee amputations.

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