title: Introducing a proforma to improve clinical care in trauma surgery.
abstract: BACKGROUND
  Accurate trauma operative details are an important part of the care of trauma patients. This study evaluated the adequacy of handwritten operative notes for trauma patients and whether they comply with the standards set by the Royal College of Surgeons of England for optimizing clinical practice in a busy district general hospital.
  
  
  METHODS
  Fifty consecutive sets of handwritten trauma operative notes were reviewed prospectively. A standardized printed proforma was introduced and then another 50 consecutive sets of notes were reviewed. The results were analysed using the Student t-test to obtain two-tailed P values comparing the mean difference between percentages of missing data for both cycles.
  
  
  RESULTS
  Out of 24 parameters examined, 19 showed improvement after introducing the standardized proforma in trauma surgical notes. There was an overall significant improvement in the studied parameters (P= 0.0134), with a mean difference of 19.3% of missing data for both cycles.
  
  
  CONCLUSIONS
  These results suggest that a standardized prestructured operative note proforma in trauma surgery is a useful tool in recording the operative data, thus helping to improve the medical care provided. It would also provide medicolegally sound evidence of a procedure when needed and so be more beneficial for the surgeon if routinely used. The authors recommend its regular use in different surgical specialties.
authors.affiliation: Clinical Fellow in the Department of Trauma and Orthopaedics, Epsom & St. Helier University Hospitals NHS Trust, Carshalton, Surrey.
authors.forename: Amr S
authors.initials: AS
authors.lastname: Hussien
authors.affiliation: Lecturer and Consultant in Trauma and Orthopaedic Surgery in the Faculty of Medicine, Suez Canal University, Ismailia 41111, Egypt.
authors.forename: Mohamed A
authors.initials: MA
authors.lastname: Imam
authors.affiliation: Research Projects Leader in the Department of Trauma and Orthopaedics, South West London Elective Orthopaedic Centre.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Elsherbiny
authors.affiliation: Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Epsom & St. Helier University Hospitals NHS Trust, Carshalton, Surrey.
authors.forename: Najab
authors.initials: N
authors.lastname: Ellahee
mesh_terms: D004282:Documentation / Q000592:standards*; D004739:England; D006769:Hospitals, General; D006801:Humans; D005791:Patient Care / Q000592:standards*; D011446:Prospective Studies; D058996:Quality Improvement; D013514:Surgical Procedures, Operative; D014947:Wounds and Injuries / Q000601:surgery*