The Sunnybrook Neurotrauma Assessment Record: improving trauma data collection.
A neurotrauma assessment record has been designed to aid in data collection and clinical documentation of patients with multiple injuries. The record collects data concerning patient demography, trauma and medical history, neurological and systemic examinations, investigations, and treatment planning. It consists of two pages and the clinician need only circle listed choices, write focused comments, or draw on provided diagrams. It obviates the narrative record of the history and physical examination. We reviewed the written records of 100 consecutive polytraumatized patients seen in the Trauma Room before institution of the form, transcribing their information onto the form. These were compared to a second series of 100 consecutive patients who were evaluated following the introduction of the neurotrauma form as the initial assessment record. Seventy-seven of these patients were evaluated by the Neurosurgical service. Overall, the quality and completeness of recording improved dramatically. The neurotrauma assessment record ensures more complete recording of information during initial patient assessment, allows easy transfer to computerized databases, and may assist academic centres in performing clinical research.
Kondziolka
D
D
Division of Neurosurgery, Sunnybrook Medical Centre, University of Toronto, Ontario, Canada.
Schwartz
M L
ML
Walters
B C
BC
McNeill
I
I
D006801:Humans; D008499:Medical Records; D009493:Neurosurgery; D020196:Trauma, Nervous System