title: Efficiencies gained by using electronic medical record and reports in trauma documentation.
abstract: Despite successful implementation of an electronic medical record (EMR) by many health care organizations, information regarding EMR for trauma resuscitation is limited, and few have created reports that facilitate trauma registry data abstraction, performance improvement reviews, and provider care requirements. In October 2010, our organization implemented an EMR for trauma resuscitations. A collaborative committee was formed to standardize data elements. Documentation compliance was monitored pre- and post-EMR implementation. Median monthly documentation completion improved from 82% to a sustained median score of 96.5% for the past 603 activations. Documentation compliance enabled the development of succinct reports that facilitate our internal needs and supported our trauma center reverification site visit.
authors.affiliation: Department of Trauma (Mss D'Huyvetter and Lang), Department of Nursing (Ms Heimer), and Department of General and Vascular Surgery, Gundersen Health System (Dr Cogbill), La Crosse, Wisconsin.
authors.forename: Cecile
authors.initials: C
authors.lastname: D'Huyvetter
authors.forename: Ann M
authors.initials: AM
authors.lastname: Lang
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Heimer
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Cogbill
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration; D004282:Documentation / Q000379:methods*; D017598:Efficiency, Organizational; D057286:Electronic Health Records / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement; D012042:Registries; D012151:Resuscitation / Q000379:methods / Q000451:nursing*; D014193:Trauma Centers / Q000458:organization & administration*