Patient File Notes for an RTA Case in Surgery

1. Patient Identification (Front Sheet)

• Full name, age, sex, address
• Date and time of admission
• MLC (Medico-Legal Case) number - mandatory for all RTA cases
• Referring doctor / brought by (police, ambulance, bystander)
• Name and contact of relative / informant
• Mode of transport (ambulance, private vehicle, etc.)

2. MLC Entry / Police Intimation

• MLC must be registered at the time of admission (even before full assessment if the patient is critical)
• Note date and time of MLC registration
• Police station informed: Yes/No, time of intimation
• Note who gave the information (patient, bystander, police)
• In unconscious patients - note that consent is implied under emergency

3. History (Subjective - as told by patient or informant)

• Mechanism of injury: "Patient was riding a two-wheeler and was hit by a car from behind at approximately 8 PM..."
• Date, time, and place of accident
• Type of vehicle involved (two-wheeler, pedestrian, car occupant)
• Was patient wearing a helmet / seatbelt? (medico-legally important)
• Brought directly or referred from another hospital?
• Any treatment given prior to arrival (first aid, surgery elsewhere)
• Last meal time (important for anaesthesia)
• Complaints on presentation: pain, bleeding, inability to move limb, loss of consciousness, vomiting, etc.
• History of LOC (loss of consciousness): duration, any amnesia (retrograde / anterograde)
• Tetanus immunization status

4. Past History

• Any prior surgery, medications, allergies
• Comorbidities: diabetes, hypertension, cardiac disease, bleeding disorders
• Drug history (anticoagulants, aspirin, steroids)

5. General Examination (on arrival)

• General condition: conscious / disoriented / unconscious
• GCS (Glasgow Coma Scale): Eye (E) + Verbal (V) + Motor (M) - total score and breakdown
• Pulse: rate, rhythm, volume, character
• BP (both arms if spinal injury suspected)
• Respiratory rate
• SpO2
• Temperature
• Pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema (PICCLE)

6. Primary Survey (ABCDE - Trauma Protocol)

7. Secondary Survey (Head to Toe Examination)

Head and Neck

• Scalp laceration, hematoma, skull tenderness
• Pupil: size, shape, reaction to light (PERL - Pupils Equal and Reactive to Light)
• Ear: Battle's sign (mastoid ecchymosis), haemotympanum
• Eyes: periorbital ecchymosis (raccoon eyes), subconjunctival hemorrhage
• Nose: CSF rhinorrhoea, bleeding
• Neck: tenderness, spinal tenderness, JVD

Chest

• Respiratory movement symmetry
• Tenderness over ribs / sternum
• Air entry bilaterally
• Any external wound, tyre marks, seat belt marks

Abdomen

• Tenderness, guarding, rigidity
• Distension
• Bowel sounds
• External bruising / tyre marks

Pelvis

• Pelvic compression test
• Perineal injuries

Spine

• Midline tenderness, step deformity
• Log roll examination

Extremities

• Deformity, swelling, tenderness
• Distal neurovascular status (pulse, sensation, capillary refill, movement)
• Open vs closed fractures - wound size and description
• Compartment syndrome signs

8. Wound Description (Medico-Legal Importance)

• Location: anatomical site (e.g., "anterior aspect of left leg, 8 cm below the tibial tuberosity")
• Size: length x width x depth (in cm)
• Shape: linear, irregular, stellate
• Edges: regular, irregular, inverted, everted, clean-cut, ragged
• Base: bone visible, tendon visible, healthy granulation
• Age: fresh / healing
• Type of injury: laceration, abrasion, contusion, penetrating wound
• Any foreign body (glass, gravel, paint)
• Any associated findings (tyre marks indicate run-over)

This description carries legal weight in court. Write it clearly, using objective terms.

9. Investigations Ordered (note time ordered and time received)

• CBC, RFT, LFT, blood group and cross-match, coagulation profile
• Blood sugar (bedside and fasting)
• Urine routine, urine for myoglobinuria if crush injury
• X-rays: chest, pelvis, c-spine, relevant limbs
• CT scan: head, abdomen, thorax, spine (specify what was done)
• FAST (Focused Assessment with Sonography in Trauma) - note findings
• ABG if needed
• ECG

10. Diagnosis (Initial and Final)

• Write all injuries as a list (Injury Severity Scoring can be referenced)
• Example:
  • Closed fracture right femur shaft
  • Traumatic splenic laceration (grade III)
  • Diffuse axonal injury
  • Road rash abrasions over left forearm

11. Treatment Notes

• Resuscitation: IV fluids (type, volume, rate), blood transfusion
• Medications: analgesics, antibiotics (note dose, route, time)
• Tetanus prophylaxis: TT / TIG given
• Wound care
• Splinting / immobilization done
• Catheterization, NGT if placed
• Consent obtained for surgery (note who signed - patient or guardian)

12. Operative Notes (if surgery done)

• Date and time of surgery
• Anaesthesia type (GA / SA / LA)
• Position of patient
• Surgeons present (operating surgeon, assistant)
• Incision and approach
• Intraoperative findings (describe exactly - e.g., "haemoperitoneum approximately 800 mL, splenic laceration 4 cm on inferior pole")
• Procedure performed step by step
• Implants used (with batch number / serial number for legal traceability)
• Blood loss (estimated), fluids given, transfusion
• Drains placed (type, location)
• Closure technique
• Patient condition at end of surgery and transfer to recovery/ICU

13. Post-operative Notes

• Daily progress notes: condition, vitals, wound, drain output
• Analgesic and antibiotic plan
• Physiotherapy
• Complications if any

14. Important Medico-Legal Points

• Never alter or overwrite any entry; corrections must be struck through with a single line, dated, and signed
• Write in black or blue ink (not pencil)
• Every entry must have date, time, and signature with designation
• In case of death, document time of death and notify police immediately
• Document if the patient gives history of assault or self-harm separately
• All MLC documents may be summoned by court - write as if you are writing for a judge