Do preformatted charts improve doctors' documentation in a rural hospital emergency department? A prospective trial.
OBJECTIVE
To determine if the introduction of preformatted patient record charts improved documentation by doctors in a rural emergency department.


METHODS
All medical records of patients who were discharged from the emergency department were collected and analysed for a period of two weeks (control). The preformatted patient charts were then introduced for a further two weeks, and analysed for the presence or absence of key content items


RESULTS
After exclusions, 137 control charts and 96 preformatted charts were collected and analysed. It was found that, overall, there was a significant improvement in the number of the key items documented (p<0.005). There was a trend towards improvement in four parameters, but for three other key content items, there was a nonsignificant decline in documentation standards.


CONCLUSIONS
A structured proforma does improve documentation. However, the improvement is small and further studies are required before use of preformatted patient records for the undifferentiated emergency department patients can be recommended.
O'Connor
A E
AE
Thames Hospital. Alan.O'Connor@act.gov.au
Finnel
L
L
Reid
J
J
D004282:Documentation / Q000592:standards*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D005568:Forms and Records Control; D006780:Hospitals, Rural; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D008505:Medical Staff, Hospital; D009520:New Zealand; D011336:Probability; D011446:Prospective Studies; D011787:Quality of Health Care; D012016:Reference Values; D012680:Sensitivity and Specificity