Trauma report · REMA score
A trauma report considers the medical consequences of trauma and assesses the trauma score on the basis of the available documentation and the methodological rules applicable to each matter.
01 / Scope
The assessment considers documented injuries, treatment, medical progress and any persistent consequences, insofar as these are supported by the available records and can be assessed objectively.
The trauma score is determined in accordance with the applicable methodology, not by informal estimation and not according to an outcome sought by the person making the enquiry.
02 / Documentation
The exact list is determined individually. Missing documents may limit or delay the formulation of conclusions.
03 / Process
The purpose of the assessment and the required competence are clarified.
The completeness, chronology and relevance of the medical documentation are considered.
The information is analysed in relation to the applicable trauma methodology.
Conclusions are written clearly and any identified limitations are stated.
04 / Independence
No value or conclusion can be promised before the assessment. The outcome depends on the individual circumstances, available documents and findings that can be supported medically.