Level 2 Trauma Chart Record Review
Data Definition Tool
The Level 2 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.
Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. The Pediatric Emergency Department will complete a minimum of 5 audits per month.
Updated: 11-12-14
Question
Standard
Location
Yes
No
N/A
1 Medical Record Number:
2 Date of Service Reviewed
All team members' names and time to
room documented?
(ED Attending MD, ED Resident MD, RN
3 1, RN 2/EMT, RT)
Trauma
Service
Guidelines
Level 2 designation appropriate for
4 patient?
Trauma
Service
Guidelines
If new Level designated, were time and
5 reason documented?
6 Mechanism of trauma documented?
Brief description of trauma/injury
7 documented?
NA
NA
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Patient Medical Record
Patient Medical Record
Pediatric Emergency Critical Care/ All team member names
Incompletely filled out
Trauma Nursing Assessment
present along with times of or missing team
(Trauma chart) page 1
arrival
member names
Patient does not meet
Patient meets Level 2
Level 2 criteria
Trauma designation
criteria according to Trauma according to Trauma
trauma chart page 1
Service Criteria
Service Criteria
Trauma chart page 1
Patient
New level designation, time New level designation remained Level
of redesignation, and reason without documentation 2 status for
for redesignation
of time or reason for
duration of
documented
redesignation
stay in ED
Documentation of
Documentation of
mechanism of injury not
mechanism of injury present present
Trauma chart page 1
Brief description present
Trauma chart Nursing notes
Brief description not
present
8 Primary Survey completed?
Vital signs recorded at appropriate
9 intervals?
10 All medications cosigned?
11 Intake and Output recorded?
12 Time to CT scan recorded?
Time patient transferred out of trauma
13 bay recorded?
14 Chart signed by RN?
15 Chart signed by MD?
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma
Service
Guidelines
Trauma chart page 2
Every element of primary
survey contains
documentation of patient
condition
Trauma chart page 3
Vital signs not
documented at
Vital signs recorded q15min appropriate intervals for
x 1 hr, q30min x 2 hr, q1h
duration of designation
after that
as trauma patient.
Trauma chart p. 3
Trauma chart page 4
trauma chart page 3 or 4
trauma chart page 4
trauma chart page 4
trauma chart page 4
Patient was given
medications; all medications
have two initials, with
initialing individuals'
signatures below
Not all elements of
primary survey contain
documentation
Patient was given
medications, but not all
medications have two Patient did not
sets of intials with
receive
signatures below.
medications
Intake and output
Intake and ouput
documentation are present, documentation are not
even if both values are zero. present.
Patient received CT but
time to CT is not
Time to CT is documented documented
Patient transferred out
of trauma bay, but time
transferred out of
Time transferred out of
trauma bay not
trauma bay documented
documented
RN signature present
RN signature not
present
MD signature present
MD signature not
present
Patient did not
receive CT scan
Patient
remained in
trauma bay for
duration of
stay
16 Critical care time documented?
Trauma
Service
Guidelines
trauma chart page 4
Critical care time
documented
Critical care time not
documented