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Results of a simple intervention to improve documentation quality in major trauma
dc.contributor.author | Twaij, Ahmed | |
dc.contributor.author | Cordido, Fernando | |
dc.contributor.author | Maryosh, Jalal | |
dc.contributor.author | Pucher, Philip H. | |
dc.date.accessioned | 2024-09-03T09:36:05Z | |
dc.date.available | 2024-09-03T09:36:05Z | |
dc.date.issued | 2015-04 | |
dc.identifier.citation | Twaij A, Carballido FC, Maryosh J, Pucher PH. Results of a simple intervention to improve documentation quality in major trauma. Eur J Emerg Med. 2015 Apr;22(2):117-20. | es_ES |
dc.identifier.issn | 0969-9546 | |
dc.identifier.uri | http://hdl.handle.net/2183/38815 | |
dc.description.abstract | [Abstract] Objectives: Accurate and thorough documentation is an important part of medical care, providing a legally binding historical record of events and means of communication. Trauma is a complex multidisciplinary environment, in which documentation is particularly important, but can be poor as a result. We investigate the effect of introducing a proforma documentation booklet, acting as a physical prompt to ensure full patient assessment, as well as full documentation, on documentation quality. Methods: A case note review of all major trauma patients admitted over 12 months at a district hospital was performed by clinicians with case note review experience 6 months before and after introduction of a trauma booklet. Documentation quality was assessed, as was the presence of complete trauma teams. Results: A total of 297 consecutive trauma patients over 12 months were reviewed: 136 patients preintervention and 161 patients after implementation of the trauma booklet. Use of a trauma booklet significantly increased the rate of primary survey documentation [82.8% (114/136) vs. 98.8% (159/161), χ P<0.001]. Similar results were seen for documented completion of secondary surveys [39% (53/136) vs. 66.5% (107/161), P<0.001]. Following implementation of a trauma booklet, a significant increase in full trauma team presence was observed (43.4 vs. 67.1%, P<0.001). Conclusion: This study has demonstrated the potential of the introduction of a structured proforma to significantly improve documentation quality in major trauma. In the future, all hospitals accepting trauma patients could benefit from the introduction of similar proformas. | es_ES |
dc.language.iso | eng | es_ES |
dc.publisher | Wolter Kluwer Health | es_ES |
dc.relation.uri | https://doi.org/10.1097/mej.0000000000000129 | es_ES |
dc.subject | Assessment | es_ES |
dc.subject | Communication | es_ES |
dc.subject | Critical care | es_ES |
dc.subject | Documentation | es_ES |
dc.subject | Primary survey | es_ES |
dc.subject | Secondary survey | es_ES |
dc.subject | Surgery | es_ES |
dc.subject | Trauma | es_ES |
dc.title | Results of a simple intervention to improve documentation quality in major trauma | es_ES |
dc.type | info:eu-repo/semantics/article | es_ES |
dc.rights.access | info:eu-repo/semantics/openAccess | es_ES |
UDC.journalTitle | European Journal of Emergency Medicine | es_ES |
UDC.volume | 22 | es_ES |
UDC.issue | 2 | es_ES |
UDC.startPage | 117 | es_ES |
UDC.endPage | 120 | es_ES |
dc.identifier.doi | 10.1097/MEJ.0000000000000129 |
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