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The Sunnybrook Neurotrauma Assessment Record: improving trauma data collection
D Kondziolka1, M L Schwartz, B C Walters
1Division of Neurosurgery, Sunnybrook Medical Centre, University of Toronto, Ontario, Canada.
The Journal of Trauma
|June 1, 1989
Summary
A new neurotrauma assessment record significantly improved data collection and clinical documentation for polytraumatized patients. This standardized form enhances information completeness and facilitates research, benefiting patient care.
Area of Science:
- Neuroscience
- Trauma Surgery
- Medical Informatics
Background:
- Effective data collection is crucial for managing polytraumatized patients.
- Current documentation methods can be inconsistent and incomplete.
- Standardized assessment tools are needed to improve clinical practice and research.
Purpose of the Study:
- To design and evaluate a novel neurotrauma assessment record for polytraumatized patients.
- To improve the quality and completeness of initial patient documentation.
- To facilitate data transfer for clinical research.
Main Methods:
- Development of a two-page neurotrauma assessment record simplifying data entry.
- Retrospective review of 100 patient records before form implementation.
- Comparison with 100 patient records evaluated using the new form.
- Analysis of data quality and completeness.
Main Results:
- The neurotrauma assessment record led to a dramatic improvement in recording quality and completeness.
- The form simplifies documentation by using circled choices, focused comments, and diagrams.
- Seventy-seven percent of patients in the second series were evaluated by the Neurosurgical service.
Conclusions:
- The neurotrauma assessment record enhances the completeness of initial patient assessments.
- The form facilitates easy transfer of data to computerized databases.
- This tool can support clinical research in academic centers.