Introducing a proforma to improve clinical care in trauma surgery

Hussien, Amr S, Imam, Mohamed A, Elsherbiny, Mohamed and Ellahee, Najab (2015) Introducing a proforma to improve clinical care in trauma surgery. British Journal of Hospital Medicine, 76 (8). ISSN 1750-8460

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Introduction: 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. Patients and 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.

Item Type: Article
Faculty \ School: Faculty of Medicine and Health Sciences > Norwich Medical School
Depositing User: LivePure Connector
Date Deposited: 15 Jul 2019 10:46
Last Modified: 22 Oct 2022 05:02
DOI: 10.12968/hmed.2015.76.8.472

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