title: Improving trauma documentation in the emergency department.
abstract: Adequate and complete trauma documentation continues to be a struggle for many health care institutions. A recently accredited Pennsylvania trauma center shared its struggles and successes in the improvement of trauma documentation in the emergency department. Such interventions included education for new nurses and ongoing education, a user-friendly trauma flow sheet, and a peer review process. Fewer documentation deficiencies were seen after the implementation of such interventions. Variables found to have a positive impact on these results were recognition of patients with low severity injuries, the peer review process, and emergency department administrative involvement.
authors.affiliation: Department of Trauma Surgery (Mrs O'Connor and Mrs Heller-Wescott), and Department of Emergency Services (Mr Raposo), Geisinger Wyoming Valley, Wilkes-Barre, Pennsylvania.
authors.forename: Tammy L
authors.initials: TL
authors.lastname: OʼConnor
authors.forename: E Andrew
authors.initials: EA
authors.lastname: Raposo
authors.forename: Teri
authors.initials: T
authors.lastname: Heller-Wescott
mesh_terms: D016208:Databases, Factual; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008991:Monitoring, Physiologic / Q000379:methods; D010414:Pennsylvania; D058996:Quality Improvement; D012042:Registries; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy