Trauma form documentation in major trauma.
OBJECTIVE
To examine the impact of a standardised trauma form for documentation in cases of major trauma, a prospective study was undertaken.


METHODS
Records written by medical staff pertaining to the assessment and treatment of major trauma patients in the resuscitation room were scored against a panel of parameters derived from advanced trauma life support guidelines. Demographics, aetiology, trauma scores and outcome data were obtained from a trauma registry. Attitudes of medical staff involved in major trauma to the trauma form were assessed using a questionnaire.


RESULTS
The trauma form was used in 53 of 69 (76.8%) consecutive cases of major trauma seen over a three month period. No significant differences existed in demographics, aetiology, trauma scores or outcome between form and formless groups. In the form group, a median of 44 of 51 (86.3%) relevant information parameters were documented versus 32 of 51 (62.7%) in the formless group, p < 0.0001. A positive approach to the trauma form was indicated by the questionnaire results.


CONCLUSIONS
The use of a standardised form improves documentation in major trauma.
Hamill
J
J
Trauma Services, Auckland Hospital. hamill@clear.net.nz
Paice
R
R
Civil
I
I
D000063:Accidents, Traffic / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004282:Documentation / Q000379:methods*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005568:Forms and Records Control / Q000379:methods*; D006801:Humans; D008297:Male; D008485:Medical Audit; D008499:Medical Records; D008875:Middle Aged; D009520:New Zealand / Q000453:epidemiology; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D014947:Wounds and Injuries / Q000453:epidemiology* / Q000209:etiology