What details should be documented for each DCAP-BTLS finding during the secondary survey?

• A. Only location
• B. Location, size, depth, mechanism, progression; document deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, swelling
• C. Date of injury only
• D. Time since injury only

Answer: (B)

In the secondary survey, documenting each DCAP-BTLS finding requires capturing exactly where the injury is and how extensive it is, plus how it happened and whether it’s changing over time. For every area you assess, note the location and measure size, note depth for wounds or penetrations, and record the mechanism of injury if it helps explain surrounding damage. Then track progression, describing whether swelling, tenderness, or other findings are increasing, decreasing, or remaining the same since the last exam. For each region, indicate which DCAP-BTLS elements are present—deformities, contusions, abrasions, penetrations, burns, tenderness, lacerations, and swelling. This level of detail creates a precise, communicable picture that guides treatment decisions (immobilization, imaging, wound care, analgesia, specialist consult) and provides a baseline to detect any changes on subsequent assessments.