History of Present Illness Template for Motorcycle Accident Patients
A comprehensive HPI template for motorcycle accident patients should include mechanism of injury details, vital signs assessment, and systematic evaluation of all body systems to identify potentially life-threatening injuries requiring trauma center care.
Initial Assessment
Vital Signs and Level of Consciousness
- Glasgow Coma Scale (GCS) score (≤13 indicates need for trauma center) 1
- Systolic blood pressure (<90 mmHg indicates need for trauma center) 1
- Respiratory rate (<10 or >29 breaths per minute indicates need for trauma center) 1
- Heart rate and oxygen saturation
- Temperature
Mechanism of Injury (Critical Information)
- Speed at time of crash (>20 mph indicates need for trauma center) 1
- Type of collision (vehicle vs. motorcycle, fixed object, etc.)
- Ejection from motorcycle
- Helmet use and condition post-crash
- Protective gear worn (jacket, gloves, boots)
- Position on motorcycle (driver vs. passenger)
- Time of accident (note: 39.9% of delivery motorcycle crashes occur between 17:00-21:00) 2
- Road and weather conditions
Focused History
Immediate Post-Injury Information
- Loss of consciousness (duration and if present)
- Memory of events before, during, and after crash
- Initial symptoms at scene
- Interventions performed at scene
- Time from injury to presentation
Pain Assessment
- Location of pain (specific body regions)
- Severity (0-10 scale)
- Quality (sharp, dull, radiating)
- Aggravating/alleviating factors
- Temporal pattern since injury
Systems Review for Injury Patterns
Head and Neck
- Headache, dizziness, vision changes
- Neck pain, stiffness, or limited range of motion
- Facial pain or trauma
Chest
- Chest pain or pressure
- Difficulty breathing
- Rib pain or tenderness
Abdomen
- Abdominal pain or tenderness
- Nausea or vomiting
- Last oral intake
Extremities
- Pain, deformity, or decreased function in limbs
- Numbness or tingling
- Note: Delivery riders have higher proportion of extremity injuries compared to other motorcycle crashes 2
Spine
- Back or spine pain
- Numbness, tingling, or weakness in extremities
- Bowel or bladder dysfunction
Patient Background
Medical History
- Pre-existing medical conditions
- Current medications
- Allergies
- Last tetanus immunization
- Baseline functional status
Risk Factors (Special Considerations)
- Age (>55 years increases risk of injury/death) 1
- Anticoagulant use 1
- Pregnancy >20 weeks 1
- End-stage renal disease requiring dialysis 1
- Frailty assessment for elderly patients 1
Social History
- Alcohol or substance use prior to accident
- Occupation (note if patient was working as delivery rider) 2
- Living situation and available support for discharge planning
Documentation Pitfalls to Avoid
- Failure to document helmet use and other protective equipment
- Incomplete documentation of mechanism of injury details
- Missing documentation of loss of consciousness or amnesia
- Inadequate pain assessment across all body regions
- Not documenting time course from injury to presentation
- Overlooking subtle signs of internal injuries in elderly patients 1
- Be aware that patients may underreport pre-existing conditions, especially when they perceive the accident was another's fault 3, 4
Trauma Triage Considerations
Document findings that would warrant trauma center transfer according to the CDC Field Triage Guidelines 1:
- Physiologic criteria: GCS ≤13, SBP <90 mmHg, RR <10 or >29
- Anatomic criteria: Penetrating injuries, chest wall instability, two or more proximal long-bone fractures, crushed extremities, pelvic fractures, open skull fractures, paralysis
- Mechanism criteria: Motorcycle crash >20 mph
- Special considerations: Age >55 years, anticoagulation, pregnancy >20 weeks