title: Use of the electronic medical record for trauma resuscitations: how does this impact documentation completeness?
abstract: Although many trauma centers across the country have implemented electronic medical records (EMRs) for inpatient documentation, they have avoided the use of EMR during the fast-paced trauma resuscitations. The objective of this study was to determine whether documenting electronically during trauma resuscitations has resulted in improvement or degradation of the completeness of data recorded. Forty critical data points were evaluated in 100 pre-EMR charts and 100 post-EMR charts. There was improvement in completeness of charting in 25% of the electronic records reviewed and degradation of completeness of charting in 18% of the records, for a net improvement in completeness of charting of 7% in the electronic records reviewed.
authors.affiliation: Trauma Program, Oregon Health & Science University, Portland, OR 97289, USA. bilyeup@ohsu.edu
authors.forename: Pam
authors.initials: P
authors.lastname: Bilyeu
authors.forename: Lynn
authors.initials: L
authors.lastname: Eastes
mesh_terms: D004282:Documentation / Q000592:standards / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D009737:Nursing Records / Q000592:standards; D012151:Resuscitation; D012189:Retrospective Studies; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000451:nursing / Q000628:therapy*