Although I agree you don't need the detail.....doctors do use common language as much as possible when informing patients and family, if you want an idea about how doctors go about recording information I can probably help.
A typical casualty set of records for an injury would probably start with a an obvious statement about any life threatening problems e.g. patient unconscious and bleeding profusely from ........ this statement is what you see in the few seconds you have standing at the bottom of the bed and should be obvious to anyone, medically trained or not.
Next, doctors always do ABC...airway, breathing, circulation. If any of them aren't working then they need urgent attention. We probably wouldn't feed this back if they were fine, but it's our starting point.
Next you'd probably see a crude picture of a body with obvious injuries marked on it. Cuts, broken bones and things like metal bars poking out from the chest would be shown on it. think of it as a crude pencil diagram of what a photo would show but with broken bones marked too.
Next a systems enquiry is done:
Heart and cardiovascular system
Respiratory system
Digestive system
Genitourinary (including kidneys) (GU)
Nervous system
Skin
Miscellaneous (eg immune system)
Next we'd report on blood results, etc.
A medical report, whether verbal or written will follow roughly the order we gather the information in....but we'd omit anything irrelevant. when talking to other doctors we'd mention in passing that things were "ok", but with families we'd typically only say the big things like "heart" was ok. They really don't care that GU was ok. instead they care about what we're doing so we mix the treatment details in early...with another doctor we'd probably leave them to the end. (Doctors care about what they still have to do, not the details of what you've done) For a death we'd omit everything and only give the details of the injuries that caused the death.
So talking to another doctor, I'd say something like:
Mr Smith was admitted unconscious with significant blood loss from a large wound on his right shoulder. His airway was clear but breathing was hampered by three broken ribs. Pulse was ..... blood pressure was low at .... due to the blood loss. Oxygen saturation was 90%. He has a complex fracture of his pelvis and a dislocated fracture of his right femur. Systems enquiry showed cardiovascular system was fine except for the low blood pressure, lungs were clear. Abdoman showed extensive bruising but examination did not reveal any obvious complications, even with the fractured pelvis but we're still waiting on the abdominal x-ray report. GU (genitourinary) was unremarkable but a catheter was passed to prevent retention (of urine). Neuro revelead..........whatever you want it to show but we'd report on level of consciousness and responsiveness (google glasgow coma score (GCS) for details...we'd typically say what the GCS was). We'd report on pupil size and reactivity....what we could see through an opthalmoscope, cranial nerves, muscle power, tone and relexes. Investiagtions revealed......(report on bloodwork and minor x-ray findings here.Wouldn't be done if dead on arrival). Current treatment is transfusion to replace the lost blood and oxygen to keep his sats up. Prognosis is we need to open him up to pin the pelvis, might need to pin the femur too. Wound on his shoulder has stopped bleeding but needs cleaning and suturing and his oxygen sats and GCS need to be monitored.
Doctors use the word examination to report on what they saw or found by putting hands on a patient and investigation to report on anything a machine did or you got from a blood test or x-ray.
Talking to a patient of family member would be very different. Here you mix in a lot more of what you did.
Your husband was unconscious when he arrived and he'd lost a lot of blood. He'd broken his pelvis and leg, and a few ribs. His blood pressure was low so we've put him on a drip to replace some fluid, but his heart is ok and he's breathing alright but we've given him some oxygen to make sure.We're going to have to sort out the pelvis next. He'll probably need an operation and we need to make sure he's not bleeding internally from that. It's quite a bad break.There are a few signs that he might have a head injury. His pupils aren't reacting very well but we won't know much more until he wakes up.
The reason for brevity is that your audience is in shock and they will only remember a couple of things and what you're going to do. everything else will fly in one ear and out the next.
Reporting a cause of death would give even less.
I'm sorry but your husband's injuries were too extensive and he died shortly after he got here. We tried CPR but he didn't respond. He'd lost too much blood from his shoulder and he might have been bleeding internally too as he'd broken his pelvis and his leg.There are signs he might have also hit his head.
Your audience is even more shocked and will barely remember speaking to you...maybe just a few choice words. They'll tune out as soon as you use the word died. everything except the probable cause of death becomes irrelevant.
hope this helps
Craig
