Improving documentation of head injured patients admitted to the emergency department ward

Well-written and factually accurate medical records are one of the cornerstones of Emergency Medicine. This audit aimed to assess whether documentation could be improved for head injured patients admitted to the Emergency Department observation ward using a pre-printed proforma.

In the first phase the notes of a consecutive series of forty patients admitted for observation to an Emergency Department ward after sustaining a head injury were prospectively audited. A data collection instrument was designed to measure the presence or absence of documentation of mechanism of injury, specific symptoms, signs, medications, investigations and treatment considered essential for gold standard head injury management. In the second phase a specially designed proforma was introduced for all patients being admitted for observation. The notes of a second consecutive series of forty patients were then audited using the same data collection instrument.

The first phase of the audit revealed inadequate documentation with regard to many of the measured variables. Significant Improvements were noted in all measured variables after the introduction of the proforma.

Documentation of all important positive and negative signs in head injured patients can be time consuming and often a challenge for doctors working in busy Emergency Departments. Accurate documentation is however important from both a clinical and a medico-legal position and this audit have shown that the introduction of a customized proforma can improve the quality of documentation. In addition clinical management of head injured patients may improve as the proforma also acts as a prompt for their subsequent investigation and treatment.