Trauma Nurse Recorder - Society of Trauma Nurses

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TRAUMA TEAM RESPONSIBILITIES
EMERGENCY DEPARTMENT NURSES
ROLE:
Recorder Nurse/ Team leader
NOTIFICATION:
Charge Nurse, overhead page
POSITION:
Doorway, foot of the bed
I.
RESPONSIBILITIES:
Accountable to the Trauma Surgeon/ Team Captain
Will be the direct link from the surgeon to the other members of the
Trauma Team
C. Ensures thorough documentation, proper labeling, and disposition of all of
specimens and forms
D. Ensures proper identification of role assignments prior to the Trauma Blue
patient arrival and requests additional staff as needed.
E. Assumes responsibility for care of the trauma patient
A.
B.
II. PATIENT MAMAGEMENT OBJECTIVES:
A. Coordinates utilization of trauma packet and assists the registrar with
collection of patient data
B. Communicates with pre hospital providers to obtain patient information
and prior field treatment and patient response
C. Relays pertinent information to the Trauma Surgeon about the patient
condition
D. Requests a STAT page for all members of the team that are not present
E. Will receive ALL orders from the Emergency Room Physician and
Trauma Surgeon and be responsible for making sure the orders are carried
out
F. Ensures completion of trauma flow sheet and other necessary
documentation to include but not limited to:
1. Patient’s physiologic scores on arrival (obtains additional information
as needed to figure scores) and upon discharge from the Emergency
Dept
2. Initial and continual assessment of the patient, includes frequent vital
signs
3. All treatments and procedures rendered and the outcomes of such,
including times and personnel involved
4. All fluids and or/ medications given and the results
5. All diagnostic tests ordered and completed
6. Obtains AMPLE history: allergies, tetanus status, current medications,
medical history, last meal, events preceding
G. Coordinates lab, x-ray, CT, etc…
H. Releases extra staff ASAP and crowd control in room
I. Accepts all blood products from Blood Bank and checks all blood
products with the Fluid nurse
J. Will be the communication link to the Operating Room staff and
Anesthesia
K. Receives all calls and results as required
L. Maintains communication by providing continual updates to appropriate
personnel, ie: Charge Nurse, Social Worker, etc…
M. Accompanies patient to CT, OR, etc…
N. Assures completion of all procedures. Delegates tasks as required
O. Obtains rooms for the pateint when admitted, if not already done
P. Gives report to the receiving unit
Q. Review all records for completion. Gives the admitting unit a copy of the
completed chart. Completes ED charges and gives completed record to
the ED Administrative Associate.
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