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.
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.
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), χ2P<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).
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.