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Improving Trauma Documentation in the Emergency Department

O'Connor, Tammy L. RN, MSN, CEN; Raposo, E. Andrew BSN, RN, CEN, CNRN; Heller-Wescott, Teri RN

doi: 10.1097/JTN.0000000000000071
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Adequate and complete trauma documentation continues to be a struggle for many health care institutions. A recently accredited Pennsylvania trauma center shared its struggles and successes in the improvement of trauma documentation in the emergency department. Such interventions included education for new nurses and ongoing education, a user-friendly trauma flow sheet, and a peer review process. Fewer documentation deficiencies were seen after the implementation of such interventions. Variables found to have a positive impact on these results were recognition of patients with low severity injuries, the peer review process, and emergency department administrative involvement.

Department of Trauma Surgery (Mrs O'Connor and Mrs Heller-Wescott), and Department of Emergency Services (Mr Raposo), Geisinger Wyoming Valley, Wilkes-Barre, Pennsylvania.

Correspondence: Tammy L. O'Connor, RN, MSN, CEN, Geisinger Wyoming Valley, Trauma, M.C. 34-19, 1000 East Mountain Blvd, Wilkes-Barre, PA 18711 (tloconnor1@geisinger.edu).

The authors declare no conflicts of interest.

Copyright © 2014 by the Society of Trauma Nurses.