Improving the record of patient assessment in the trauma room

To facilitate clinical research at the Regional Trauma Unit at Sunnybrook Medical Centre in Toronto, it was decided to attempt to improve the quality and quantity of clinical patient information obtained at initial assessment in the Trauma Room. Standardized patient forms were introduced to replace the narrative record, including forms for the Trauma Team Leader, Anesthesia, General Surgery, Neurosurgery, Orthopedic Surgery, and Plastic Surgery. These forms were evaluated in this study which compared 100 charts generated before introduction of the forms to 100 charts generated following the implementation of the forms, with respect to certain items of patient demography and clinical condition. There was a statistically significant improvement in amount of information collected and in a format which facilitates data storage and retrieval. This, in turn, establishes an excellent standardized database for clinical trials in trauma care.