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A Comparison of Paper Documentation to Electronic Documentation for Trauma Resuscitations at a Level I Pediatric Trauma Center

      Introduction

      Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations.

      Methods

      The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n = 200) was compared with a random sample of trauma resuscitations documented electronically (n = 200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation.

      Results

      The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P < .00), primary assessment (94% vs 88%, P < .036), arrival time of attending physician (98% vs 93.5%, P < .026), intravenous fluid volume in the emergency department (94% vs 88%, P < .036), and disposition (100% vs 89.5%, P < .00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P < .00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation.

      Discussion

      Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations.

      Key words

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      Biography

      Lee Ann Wurster is Trauma Coordinator, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Carla Coffey is Trauma Coordinator, Nationwide Children’s Hospital, Columbus, Ohio.

      Biography

      Jonathan Groner is Trauma Medical Director, Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Jeffrey Hoffman is Chief Medical Information Officer, Department of Information Services, Department of Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Valerie Hendren is Epic Application Coordinator, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Kathy Nuss is Associate Director, Department of Emergency Medicine, Operations Medical Director, Emergency Department, and Associate Trauma Medical Director, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Kathy Haley, Member, Central Ohio Chapter, is Trauma Program Manager, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Julie Gerberick is Emergency Department Education Nurse Specialist, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Beth Malehorn is Emergency Department Nurse Educator, Nationwide Children’s Hospital, Columbus, OH.

      Biography

      Julia Covert is Clinical Program Manager, Nationwide Children’s Hospital, Columbus, OH.

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