I found a few on google, and a couple of books on amazon. I should have been looking for "charting."
Quick Question:
Can you guys give me some tips on describing traumatic injury. For example, deformaties, lacerations, etc. Obviously I don't expect you guys to spend your sunday evening listing abbreviations, but I'd appreciate it if you could throw in a couple useful ones when describing traumatic injury.
Thank you much 😀
See if you can't get a hold of, or look at, some T-sheets and look at one for trauma (but don't use since they're copywrited). They're made for super fast charting using a series of back slashes and circles instead of having to write out an HPI. It also has standard questions and standard responses to those questions for a quick circle or backslash. For someone premedical, this is the best way that I can think of for you to learn what needs to be documented.
Sorry, but it's going to take some "on the job training" to get used to it. You can only study so much, but using it like a second language takes practice. Where I work, the premed scribes train for a length of 8-10 shifts at 8-9 hours a shift. By the end of the training period they're usually fairly fluent with an occasional question to the doctor.
Sometimes it's easier to not use the abbreviation if you're trying to use too many. If you spend time trying to remember an abbreviation instead of writing the word, then they aren't helping. If you can't remember it right away, it's okay to use the entire word. Later you can look it up for future use.
Look online at some sample HPI's (History of Present Illness) to get an idea of what needs to be documented. Typically, for trauma, you need the onset of the injury (when it happened), what part of the body is affected, a short story about what happened, description of pain (sharp, dull, etc), is the pain constant/worsening/resolving, what exacerbates the pain (deep breaths, movement, etc), what the patient has done, if anything, to treat themselves, associated symptoms (as well as pertinent negatives-something to ask your doctor about), I'm sure I can think of more later. There's a balance of good notes and time. You can make HPI's extremely long and detailed if you spend enough time, but you may not have the time.
The doctor can give you the physical exam and they would dictate how they want things described. You can't be expected to be able to describe an exam by just looking at the person. That would be "unpossible". You might be able to get things such as "pale", "diaphoretic", "distress" and a few other things, but you should wait to get what the doctor says about that since you don't really have the medical training to make those calls.
