Establishing and Improving Role 2 Documentation Performance: A 2-Part Quality Improvement Initiative

Accurate and comprehensive medical documentation is essential to safe, effective patient care, particularly in austere environments where patients transition rapidly between teams, locations, and levels of capability. In Role 2 environments, where casualties move from point of injury through damage control resuscitation, surgery, and prolonged casualty care, information loss during transitions poses a persistent threat to patient safety. Despite the existence of Joint Trauma System (JTS) Clinical Practice Guidelines and standardized documentation tools, variability in documentation practices persists within Role 2 settings. This quality improvement (QI) project sought to evaluate whether targeted documentation and handoff training could improve self-reported provider confidence and documentation performance during a simulated operational exercise.

This 2-part QI initiative was conducted within a Role 2 military medical unit preparing for a battalion-level certification exercise. Part I consisted of targeted training for providers, nurses, and corpsmen on JTS documentation requirements and structured handoff tools (MIST, I-PASS, SBAR). Participants completed pre- and post-training surveys assessing self-reported ability and confidence across 4 competency domains. Part II evaluated documentation during a 5-day field exercise. A stratified random sample of 55 simulated casualty charts (of 100 total) was audited using a structured tool aligned with JTS key performance indicators to assess completeness, accuracy, and clinical relevance. Descriptive statistics were used to summarize findings. The project was reviewed and determined to meet criteria for quality improvement rather than human subjects research.

Forty-four personnel participated in the training intervention. Self-reported confidence and perceived ability improved significantly across all 4 domains (P < .05), with the largest improvement observed in participants' ability to identify and mitigate documentation and handoff errors. During the certification exercise, overall documentation compliance was 51%, and overall JTS compliance was 56%. Frequent deficiencies included missing reassessment vital signs, incomplete allergy documentation, absent provider orders, incomplete anesthesia records, and failure to update DD3019 forms following surgery.

This QI project established a formal baseline of documentation performance within a Role 2 unit and demonstrated that targeted training improved provider confidence but did not fully translate into consistent documentation practice during operational simulation. These findings highlight the gap between perceived competence and field execution in austere military environments. Sustained improvement will likely require repeated training cycles, integrated audit and feedback, workflow optimization, and leadership reinforcement. Strengthening documentation and structured handoffs has important implications for patient safety, trauma system performance improvement, and operational readiness across Role 2 settings.