Efficiencies gained by using electronic medical record and reports in trauma documentation

Area of Science:

• Trauma Surgery
• Health Informatics
• Medical Record Systems

Background:

• Electronic medical records (EMRs) are widely adopted in healthcare, but their application in trauma resuscitation is less documented.
• Existing EMRs often lack features for efficient trauma data abstraction, performance improvement reviews, and meeting provider care requirements.
• Limited information exists on the successful implementation and impact of EMRs specifically for the unique demands of trauma resuscitation.

Purpose of the Study:

• To describe the implementation of an EMR system tailored for trauma resuscitation.
• To assess the impact of EMR implementation on documentation compliance.
• To evaluate the utility of the EMR in facilitating trauma registry data abstraction and performance improvement.

Main Methods:

• An electronic medical record (EMR) was implemented for trauma resuscitations in October 2010.
• A collaborative committee standardized data elements within the EMR system.
• Documentation compliance was monitored before and after EMR implementation.

Main Results:

• Median monthly documentation completion improved from 82% to a sustained 96.5% post-EMR implementation.
• This sustained high compliance was observed over 603 trauma activations.
• The improved documentation facilitated the creation of reports for internal needs and trauma center reverification.

Conclusions:

• EMR implementation in trauma resuscitation can significantly enhance documentation completeness and consistency.
• Standardized data elements and focused monitoring are key to successful EMR adoption in trauma care.
• Improved EMR documentation directly supports critical functions like trauma registry abstraction and quality improvement initiatives.