title: Results of a simple intervention to improve documentation quality in major trauma.
abstract: OBJECTIVE
  Accurate and thorough documentation is an important part of medical care, providing a legally binding historical record of events and means of communication. Trauma is a complex multidisciplinary environment, in which documentation is particularly important, but can be poor as a result. We investigate the effect of introducing a proforma documentation booklet, acting as a physical prompt to ensure full patient assessment, as well as full documentation, on documentation quality.
  
  
  METHODS
  A case note review of all major trauma patients admitted over 12 months at a district hospital was performed by clinicians with case note review experience 6 months before and after introduction of a trauma booklet. Documentation quality was assessed, as was the presence of complete trauma teams.
  
  
  RESULTS
  A total of 297 consecutive trauma patients over 12 months were reviewed: 136 patients preintervention and 161 patients after implementation of the trauma booklet. Use of a trauma booklet significantly increased the rate of primary survey documentation [82.8% (114/136) vs. 98.8% (159/161), χ P<0.001]. Similar results were seen for documented completion of secondary surveys [39% (53/136) vs. 66.5% (107/161), P<0.001]. Following implementation of a trauma booklet, a significant increase in full trauma team presence was observed (43.4 vs. 67.1%, P<0.001).
  
  
  CONCLUSIONS
  This study has demonstrated the potential of the introduction of a structured proforma to significantly improve documentation quality in major trauma. In the future, all hospitals accepting trauma patients could benefit from the introduction of similar proformas.
authors.affiliation: aDepartment of Surgery and Cancer, Imperial College London, London bEast Kent Hospitals University Foundation Trust, William Harvey Hospital, Ashford, Kent, UK.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Twaij
authors.forename: Fernando C
authors.initials: FC
authors.lastname: Carballido
authors.forename: Jalal
authors.initials: J
authors.lastname: Maryosh
authors.forename: Philip H
authors.initials: PH
authors.lastname: Pucher
mesh_terms: D003422:Critical Care / Q000458:organization & administration; D003430:Cross-Sectional Studies; D004282:Documentation / Q000379:methods*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D009936:Organizational Innovation; D011785:Quality Assurance, Health Care; D015996:Survival Rate; D015599:Trauma Severity Indices; D006113:United Kingdom; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*