Ministry of Health

NZ Government

    
 ©Copyright
 Published: 09/02/2006

Documentation in Major Trauma

All members of the trauma team have a responsibility to ensure their actions, findings, names and roles are recorded in a legible fashion in the patients medical record. The Auckland Hospital Major Trauma Form is designed to document the trauma call. It forms a part of the clinical record. When used, other documentation is typically not required.

Definitive care decisions may require further documentation: speciality, specialist, plans and prioritisation. When several teams are involved explicit instructions (e.g. NBM, mobility, observations etc.) are required.

Last updated on 09/02/2006