[Admission documentation of multiple trauma patients using the Zurich Trauma Protocol--initial experiences].
A new protocol to document multiply injured patients in presented. It consists of 23 pages and is indexed on the right side. The pages are structured according to the Abbreviated Injury Scale (AIS): head/neck, face, thorax, abdomen, extremities/pelvis and integument. Different checklists on the right side of each page help to enter data efficiently; schemes and templates on the left side provide further support to visualize and classify the injuries. Summaries for diagnosis, therapies and for further investigations provide a standardized overview of the patient. The experiences of 22 residents were analyzed after one year of the protocol use. The trauma protocol was shown to be easy to learn, it was well accepted, and it increased the exchange of information between the emergency room and the intensive care unit. However, some residents considered this data entry to more laborious compared with the traditional medical record system. The trauma protocol was designed for prospective data acquisition of intensive care patients; it provides also a uniform structure for retrospective analysis and is therefore a helpful tool to increase quality control and quality assurance.
Heinzelmann
M
M
Klinik für Unfallchirurgie, Universitätsspital Zürich.
Käch
K
K
Trentz
O
O
D015998:Abbreviated Injury Scale; D001291:Attitude of Health Personnel; D003422:Critical Care; D004282:Documentation / Q000379:methods*; D006801:Humans; D007396:Internship and Residency; D009104:Multiple Trauma / Q000145:classification / Q000175:diagnosis*; D010343:Patient Admission; D011785:Quality Assurance, Health Care
Eintrittsdokumentation polytraumatisierter Patienten mit dem Zürcher Traumaprotokoll--Erste Erfahrungen.