Level 1 Trauma Chart Record Review
Data Definition Tool
The Level 1 Trauma Chart Record Review is to be completed for Pediatric Emergency Department by the manager or designee on a monthly basis. Tracers are due by
midnight of the last day of the month of the review (example: July Tracer due July 31).
Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Pediatric Emergency Department completes a minimum of 5 Level 1 Trauma Chart Record
Review audits per month.
Updated: 11-12-14
Question
Standard
Location
Yes
No
N/A
1
2
3
4
Patient Medical
Medical Record Number:
NA
Record
Patient Medical
Date of service reviewed
NA
Record
All appropriate team members'
Pediatric
names and time to room
Emergency Critical
documented?
Care/ Trauma
(Trauma Attending MD, Trauma
Nursing
Resident MD, ED Attending MD, ED
Assessment
Resident MD, RN 1, RN2, RN3/EMT, Trauma Service (Trauma chart)
SW)
Guidelines page 1
Trauma
designation
Level 1 designation appropriate for Trauma Service trauma chart page
patient?
Guidelines 1
All required team member
names present along with
times of arrival
Incompletely filled out or
missing team member names
Patient meets Level 1
Patient does not meet Level 1
criteria according to Trauma criteria according to Trauma
Service Criteria
Service Criteria
New level designation, time
of redesignation, and reason New level designation without
for redesignation
documentation of time or
documented
reason for redesignation
5
If new Level designated, was time
and reason documented?
Trauma Service Trauma chart
Guidelines Nursing notes
6
Mechanism of trauma
documented?
Trauma Service Trauma chart page Documentation of
Documentation of mechanism
Guidelines 1
mechanism of injury present of injury not present
Patient remained Level
1 status without being
downgraded
7
Brief description of trauma/injury
documented?
8
Primary Survey completed?
9
Vital signs recorded at appropriate
intervals?
Trauma Service Trauma chart page
Guidelines 1
Brief description present
Every element of primary
survey contains
Trauma Service Trauma chart page documentation of patient
Guidelines 2
condition
Brief description not present
Not all elements of primary
survey contain documentation
Vital signs not documented at
Vital signs recorded q5min x appropriate intervals for
Trauma Service Trauma chart page 20 min, q15min x 1hr,
duration of designation as
Guidelines 3
q30min thereafter
trauma patient.
10 All medications cosigned?
Patient was given
medications; all medications
have two initials, with
Trauma Service Trauma chart page initialing individuals'
Guidelines 3
signatures below
11 Intake and Output recorded?
Intake and output
Trauma Service Trauma chart page documentation are present, Intake and ouput
Guidelines 4
even if both values are zero. documentation are not present.
12 Time to CT scan recorded?
Trauma Service trauma chart
Guidelines page 3 or 4
Time patient transferred out of
13 trauma bay recorded?
Trauma Service trauma chart page Time transferred out of
Guidelines 4
trauma bay documented
Patient received CT but time to
CT is not documented
Patient transferred out of
trauma bay, but time
transferred out of trauma bay
not documented
14 Chart signed by Scribe RN?
Trauma Service trauma chart page
Guidelines 4
RN signature present
RN signature not present
15 Chart signed by Attending MD?
Trauma Service trauma chart page Attending MD signature
Guidelines 4
present
Attending MD signature not
present
Time to CT is documented
Patient was given medications,
but not all medications have
two sets of intials with
Patient did not receive
signatures below.
medications
Patient did not receive
CT scan
Patient remained in
trauma bay for
duration of stay
16 Critical care time documented?
Trauma Service trauma chart page Critical care time
Guidelines 4
documented
Critical care time not
documented