title: Tick-box admission forms improve the quality of documentation of surgical emergencies, but have limited impact on clinical behaviour.
abstract: BACKGROUND
  We used modern error theory to develop a tick-box admission form for emergency surgical patients. The tick boxes were designed to actively direct care down appropriate clinical algorithms by encouraging staff to make decisions based on recorded clinical data.
  
  
  OBJECTIVE
  To audit the effect of these tick-box forms on the quality of documentation and of the resuscitation process.
  
  
  METHODS
  We designed and implemented a standardised tick-box admission form, and audited its impact by comparing 100 emergency surgical admissions before the intervention with 100 thereafter. We assessed the quality of the documentation in both groups and analysed the effect of use of the tick-box admission form and the decision nodes on the clinical behaviour of the admitting clinicians.
  
  
  RESULTS
  The introduction of standardised tick-box admission forms dramatically improved the quality of documentation of acute surgical admissions. However, the impact of the decision nodes on clinical behaviour was less obvious. We demonstrated a tendency to cognitive dissonance in that, even though clinicians recorded abnormal physiological data, they did not consistently interpret this information correctly.
  
  
  CONCLUSIONS
  Although the use of tick-box admission forms improves the quality of documentation, the impact on clinical behaviour is less certain. Quality improvement is a multifactorial endeavour, and without a pervasive culture of patient safety, tick-boxes alone may well be ineffective.
authors.affiliation: Pietermaritzburg Metropolitan Trauma Service, KwaZulu-Natal, South Africa; Department of General Surgery, Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa. GrantLaing@live.co.za.
authors.forename: Grant L
authors.initials: GL
authors.lastname: Laing
authors.forename: J L
authors.initials: JL
authors.lastname: Bruce
authors.forename: Damian Luiz
authors.initials: DL
authors.lastname: Clarke
mesh_terms: D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records; D004630:Emergencies; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D010343:Patient Admission / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies