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Trauma - Scribing - AP

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Summary

This on-demand teaching session will provide medical professionals with an insight into the importance of quality major trauma patient documentation and the key standards for practical and accurate completion. Attendees will learn about the standardized documentation provided by the National Major Trauma Network and the tools available to help maintain high quality handover, patient assessment and documentation. Come hear about the essential requirements for patient information and documentation, as well as best practices for communication and team effort from experts!

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Learning objectives

Learning Objectives:

  1. Identify the basic features of the Major Trauma Documentation booklet.
  2. Understand the overall process by which major trauma patient information is documented, submitted, and transferred.
  3. Develop skills for efficient, accurate, and comprehensive documentation related to major trauma patients.
  4. Apply best practices for communication with the patient's family and between team members, especially during hand offs.
  5. Become familiar with sections of the documentation booklet and how to complete them appropriately.
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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Oh, so I'm going to talk about the major renovation work. Mint? Yeah, Doesn't look like the next day, so I started looking at my documentations. So what is it? Measure? Tomah is defined as injury. A combination of injuries that life threatening on could be life changing because it maybe those in long term disability, a major trauma, easily wants to be a disability. People 40 years old in the UK on one than half off major it's cause I wrote traffic, religion, major trauma patient document. So this is the booklet is developed by Know that my love, the major Triaminic Working Do 1019. It's a standardized the documentation with you know that my lunchtime a network. So no matter which hospital, you go to bed, you know the moment Amy Body's using exactly so assessment. Accurate, um, comprehensive documentation and neighbors archit well, good quality. Hand over to measure. Trauma center station is deem effort. Wolves ride a range of a difference to healthcare professionals. Different stages. I'm going with the essence care because of multiple points in the patients generally on accurate, practically behind the what's essential for submitted the transition to defend to prepare on the destination. Hum a patient documents is a relative. That's that's not it's not that it. So, um, DRM, um, is the research network the number My major? Completely. It's nets. This that a lot? Well, still, let's do this. Such network on the letter will support quality movement on the the end up in the future. Oh, the dominant work. Also major trauma patient. Um, it looks like this If you are not family aware that if you go in a major drama patient and you them over there, you can find it online on it's a 44 years. Look at on it's kept in here. And this is really tight, E. Okay, so sky, as you said earlier, sliding past, please. Very flex. Um, So what do they need to be able? A patient information. We get really a lots of it to the steam on documents. How about remember, numbers present progress documentations on insurance requirement with rest homes on peasants. Idle records at Mr Know from my, um so the Honda over. What's my, um um yeah. So it's harmed off handle. Uh, the template is going to sandwich. A passion is stable enough for hands over on hands of handle Our means. All team members silence on listening. No, not talking or not. Time to do. BP is it's It's very tempting, Teo just happy and doing observation. But this two minutes, senator, that's very important going back on. So it's not just a look, Um provides 10 minutes. Remind us to the team read on steps, all stations for its bloods. Extremely incidentally, savvy completions and physician performed on At what times? In general Attendant remember, start meant their involvement on maintains, I'm over the alongside a team leader. You, me, besides the team leader. So what we come needs to make me really a communication with the family a lot of times. So this is a little stimulation. This'll 56 year old. We have to see if it's realized to say that I'm Mr In and I'll write. It is hard on my field in Am I on. So I was ejected from the legal I'm head chest. Abdominal injuries observed. Easiest. 12 people watch every actually tonight. Uh, sounds like it's given. It's given by. So you get this information. Really? That's a massive No, I got a sudden are going to decide if a drama team activation unit e O after get terminated. Mail a saliva needs to get the documentation on fast. Page needs to be documented to this. Attending Who is doing what on, um, Father Page is the hospital information. So this needs to be documented. Try. Yeah, that's either having 100 Nice that you have the passion it's name and conditionally into These are all the signs and frequents on the bottom. But even like, yes, it's very important we let our home should a company patient Teo Hell, if it doesn't the medication. That's really important. Um, Page, it'll on page hide money same time, Yeah, so the Spiriva needs just needs to document list. Say something is a mist you need to communicate with the meat or is just, um, you know what the M Just because of Skylar, it's a party who has a who is the only person I have apparently form to get. So that is really well, so no, I can't side is Perma clonality this after it needs to be documented by driver. That's necessarily cities a while. Take a little indentation age with teammate on the either injury sampling is to leave, documented by the consultant or tingly. So less than is nursing notes. Asking us is like dio like the right, That's nobody's we handed to document a lot of different things. Just avoid the applications. We know what medications, even the drug fish. And we know that also, we don't need to duplicate it. I don't make that such a patient belongs given by nice pounds in a sealed the back or next game. You know what's happening with next up again? Who is coming on? This is, um, one of the pages of Colburn Assessment adjusted to show you the example. So it's quite, uh okay, Says Mental. Um, I'm about with, um good resuscitation also gives you the minute presentation with both these offices. So it is really good segmental as well. So in that it was end of the little result, which you can document the blood results. When you have just sick, they're printed out. It's a result on the right hand side effects may really here instrument e s a trauma team in the belief will be used to call the people leaving, prescribe the rocks. It's actually cause maybe the end of a little bit. So you you need to put it right at all these days with the government agencies. All medication is, um, documented. Didn't have. And that's it. Uh huh. The many. And the page, Page 23 24 is four months there. So the right, um, sides are all the detail. Is it asked a little bit. 20 s o jelling the patient's name. 80 Before the terms, hair of special needs to be recorded in off the church on so exciting is really complex. Last, as it mentioned earlier on term, it's a special. It's a team effort and a lot of people who don't usually work together all the time comes together. Aren't it's Tom be the environment being noisy and dynamic? Um so the stable job. It's just It's not just documenting all stations and medications. It was beyond start. You need to work alongside with the meat. It's me ascribing. It's really tempting to help fight do lot, so you do the second dose. But it's kind of needs to lead to have two doing sliding on the second job for alongside, um, maintaining clear communication with a team leader is one of the most a telling the time. My cessation has a driver. So whenever patient is transferred to the documentation in East be scams on the original documentation is the company that nature trauma center? So that's just, you know, any questions?