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Trauma Tertiary Survey

A tertiary survey (exam) should be performed on all patients admitted to the trauma service approximately 24 hours following admission/initial evaluation.  

The tertiary survey is a repeat head-to-toe examination of the trauma patient that is designed to identify injuries (usually more minor) that were not identified on the initial evaluation. Ideally the patient should be able to participate in the exam. EXCEPTION--intubated/sedated ICU patients should still receive a tertiary exam ~24 hrs following admission and also AGAIN, when his/her clinical status allows for them to participate in the exam. 

The following is included in a trauma tertiary exam:

  • complete physical exam 
  • review of any outstanding or follow-up imaging/labs/tests following initial examination/work-up 
  • review of previously diagnosed injuries and ensure injury is being addressed (i.e. consults called, treatment plans in progress, etc)
  • review of patient's medical history 
  • ensure home medications have been reconciled and resumed as indicated 
  • review current status of patient (i.e. are existing lines/tubes still needed? VTE prophylaxis initiated? Activity restrictions? PT/OT/Speech consults? etc)
  • update the patient's problems list in electronic medical records 

How to complete a trauma tertiary survey at UNMC/Nebraska Medicine 

Step 1: perform the tertiary survey

  • thorough physical exam
  • review all imaging, labs, etc. 
  • order additional imaging, labs, consults, etc. as indicated
  • review injuries, treatment plans, etc and ensure plans are progressing appropriately 

Step 2: document your tertiary survey 

  • New note
  • Note type: Trauma Tertiary Survey

Step 3: complete tertiary survey template FULLY and ACCURATELY 

  • once trauma tertiary survey is selected as note type, a trauma tertiary template will autopopulate. 
  • fill in ALL values/categories based on your repeat assessment/examination at ~24 hours following admission 
      • this includes the Tertiary Trauma Quality Improvement (TQI) Section 
          • it appears in RED on the tertiary survey template
          • this section includes certain pre-existing conditions that will be included in the trauma registry/TQIP database that help accurately capture the patient's status. 
          • to fill out this section, click on the TERTIARY TRUAMA QUALITY IMPROVEMENT (TQI) ADVANCED button at the top of the note template
          • this will pull up a second screen/menu with a list of pre-existing conditions where conditions can be selected as appropriate (see pictures below)

 

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