Observational analysis of documentation burden and data duplication in trauma patient pathways at a major trauma centre.

ABSTRACT

OBJECTIVES: Trauma patients require extensive documentation across paper and electronic modalities. The objectives of this study were (1) to assess the documentation burden for trauma patients by contrasting entries against predetermined key information elements, dubbed 'data entry points' (DEPs) of a thorough trauma clerking, and by evaluating completeness of entries; and (2) to assess documentation for repetition using a Likert scale and through identification of copied data elements. METHODS: A 1-month retrospective observational pilot study analysing documentation within the first 24 hours of a patient's presentation to a major trauma centre. Documentation was analysed across three platforms paper notes, electronic health record (EHR) and patient organisation system (POS) entries. Entries were assessed against predetermined DEPs, for completeness, for directly copied elements and for uniqueness (using a Likert scale). RESULTS: 30 patients were identified. The mean completeness of a clerking on paper, EHR and POS was 79%, 70% and 62%, respectively. Mean completeness decreased temporally down to 41% by the second ward round. The mean proportion of documented DEPs on paper, EHR and POS entries was 47%, 49% and 35%, respectively. 77% of POS entries contained copied elements, with a low level of uniqueness of 1.3/5. DISCUSSION: Our results show evidence of high documentation burden with unnecessary repetition of data entry in the management of trauma patients. CONCLUSION: This pilot study of trauma patient documentation demonstrates multiple inefficiencies and a marked administrative burden, further compounded by the need to document across multiple platforms, which may lead to eventual patient safety concerns.