469 Improving the Quality of Trauma Meeting Documentation
C R Yip, N Nadar, D Warrington, A Kassir, C Peach- Surgery
Abstract
Aim
Trauma meeting allows discussion of new referrals, formulate treatment plan and coordinate the trauma threatre list. Modern electronic patient record platform has facilitated the feasibility of real-time documentation. The purpose of this audit is to evaluate the current practice of trauma meeting documentation, subsequently implementing a proforma which provides structured and effective documentation using an electronic smart-phrase function, aiming to improve the overall quality and consistency of trauma meeting documentation.
Method
Three retrospective Plan, Do, Study, Act (PDSA) studies of ten days duration each, were performed for all patients discussed in three occasions: pre-implementation, post-implementation, and one-month post-implementation of the smart-phrase. Appropriate adjustments were made based on data analysed and multi-disciplinary feedback. Eight standards were measured which include documentation of consultant on-call, consultants present, imaging discussed, concerns from the multi-disciplinary team, diagnosis, laterality, clear plan and weight-bearing status.
Results
A total of 296 cases were discussed in three study periods, 90 cases in PDSA 1, 98 cases in PDSA 2 and 108 in PDSA 3. Only 64% of the cases discussed in PDSA 1 had documentation. Following introduction of the smart-phrase, 94% and 88% of cases discussed were documented in PDSA 2 and 3 respectively. An overall improvement was noted in all eight standards measured following implementation of the smart phrase in PDSA 2 and 3. Lack of time to complete documentation was highlighted.
Conclusions
The smart phrase has provided a structured and effective mean of documentation. However, orthopaedic consultants need to allocate more time to ensure completion of documentation for each cases discussed.