M A Ragoo, G W McNaughton
A&E Department, Royal Alexandra Hospital, Corsebar Road, Paisley
Correspondence to Dr McNaughton, A&E Department, Royal Alexandra Hospital, Corsebar Road, Paisley PA2 9PN. Email: gordon.mcnaughton@rah.scot.nhs.uk
SMJ 2005 50(3): 99-100
Abstract
Objective: 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. Methods: 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. Results: 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. Conclusions: 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.
Introduction
It is estimated that, in Scotland, one hundred thousand patients attend hospital annually following a head injury.1 Appropriate management of these patients is outlined in the Scottish Intercollegiate Guidelines Network (SIGN) recommendations for the early management of head injuries and more recently the National Institute for Clinical Excellence (NICE) guidelines.2 These guidelines highlight the small group of patients whose outcome is made worse by a failure to promptly detect and deal adequately with the complications of their head injury. It therefore seeks to reliably identify these patients based on various factors such as mechanism of injury, symptoms, signs and other risk factors including medications. The appropriate investigations are recommended and subsequent management is outlined including observation in hospital. In our department, the majority of head injured patients requiring observation are admitted to a ward under the care of the emergency department.
Previously a retrospective audit of the notes of head injured patients noted poor quality both in content and legibility of documentation by medical staff.3 Another study from the same unit showed that the introduction of a specially designed proforma improved the documentation of head injured patients treated in the emergency department.4 In our study we specifically audited the quality of documentation of head injured patients being admitted for observation. We then introduced a pre-printed proforma and re-audited the documentation of a similar number of patients.
Methods
The notes of consecutive patients admitted to the observation ward of a district general hospital in Scotland between September 2003 and December 2003 were collected and audited. The initial clinical notes prior to admission were examined for the presence or absence of various aspects of documentation. A data collection sheet was filled out for each patient. The clinicians were unaware that they were being audited in order to avoid the Hawthorne effect.5 Patients seen by the investigators were also excluded from the audit.
A specially designed pro forma for recording the clinical details was introduced and used instead of writing full notes for all head injured patients to be admitted. The proforma was attached to the clinical note by a self-adhesive strip. Doctors were encouraged to make supplemental notes in cases of multiple injuries. Following the introduction of the proforma a similar group of notes were again audited over a three-month period using the data collection sheet. The pre and post proforma results were analysed using the Chi squared test to detect if there had been significant improvements.
Results
A total of eighty sets of clinical notes were audited, fortyone prior to the introduction of the proforma and thirtynine afterwards. Documentation in freehand notes was generally of a lower standard, with frequent omissions of some of the criteria measured (Table I). Statistical significance (p<0.05) was achieved in ten of the seventeen criteria, indicating that these were more likely to be omitted in freehand notes.
The mechanism of injury was well documented before the introduction of the proforma. Symptoms such as loss of consciousness and vomiting in addition to current medications were however occasionally omitted. Other symptoms such as nausea or headache were frequently omitted prior to the introduction of the proforma. Likewise, the GCS of the patient was well documented but the pupil size and the absence of focal neurology were sometimes omitted. The initial vital signs, the presence or absence of lacerations or haematomas, CSF leaks, and the documentation of a neck examination were omitted frequently in the freehand notes. There was good documentation of investigations performed and treatment administered. After the introduction of the proforma all the measured criteria were well documented.
Discussion
The results of this audit are in keeping with previous studies showing incomplete documentation in the emergency department.3,4,6 It is perhaps concerning that some areas were poorly documented before the introduction of the proforma. This audit looked at only the medical documentation and it may well have been that some of the clinical parameters e.g. GCS and pupils were contained within the nursing notes. In busy emergency departments, medical staff may often feel pressured to see patients quickly in order to reduce waiting times however a hurried approach to note keeping can lead to poor documentation and ultimately to litigation, which may be indefensible.7
The proforma was introduced as a method of quickly and accurately recording the relevant findings in head-injured patients and the results of the audit confirm clear improvements in most areas. There has been a previous study using a proforma for all head injuries presenting to the emergency department, however there were concerns about efficiency and cost-effectiveness regarding its use in very minor head injuries. In our department we limited its use initially to patients admitted for observation. Further work is on going to develop a similar proforma for all head injured patients treated in our Emergency Department and our associated Minor Injuries Unit. Similar improvements would be anticipated in the quality of documentation.
The introduction of the proforma has had additional benefits. There is now a specific place within the records to record which radiological investigations and blood tests have been taken and to record their results in the records. We believe the proforma also acts as a simple prompt e.g. examination of the tympanic membranes may identify a base of skull fracture not otherwise visible and alert the clinician to a potentially serious problem.
The proforma also requires completion of details in relation to drug prescribing. Simple analgesia for headache, antibiotics where indicated and diazepam for alcohol withdrawal are all drugs which were often omitted when patients were initially admitted. We believe that improvements in this area may also benefit the patient and in addition reduce time spent on the ward by staff being called back to complete a drug prescription chart.
This audit has clearly demonstrated that there are benefits from the introduction of a proforma for patients with head injuries admitted to the emergency department ward. We would recommend this method of note keeping for any unit responsible for the admission and observation of head injured patients.
REFERENCES
1 Scottish Intercollegiate Guidelines Network (SIGN). Early Management of Patients with a Head Injury. (Publication No.46) SIGN Secretariat, Royal College of Physicians,2000.
2 National Institute for Clinical Excellence (NICE) publication. Head injury triage, assessment, investigation and early management of head injury in infants, children and adults. Clinical guideline 4 June2003 ( http://www.nice.org)
3 Wallace SA, Bennett J, Perez-Avila CA, Gullan RW. Head injuries in the accident and emergency department: are we using resources effectively? J Accid Emerg Med. 1994;11(1):25-31.
4 Wallace SA, Gullan RW, Byrne PO, Bennett J, Perez-Avila CA. Use of a pro forma for head injuries in the accident and emergency department-the way forward. J Accid Emerg Med. 1994;11(1):33-42.
5 Management and the worker. Roethlisberger FJ, Dickson WJ. Cambridge Massachusetts. Harvard University Press 1956.
6 McNaughton GW, Hislop LJ, Grant PT Medical documentation in an Accident and Emergency department. Medical Audit News 1995; 5(4): 53-54.
7 Garfield J. Head injuries and litigation. Journal of the Medical Defence Union 1991;1:2-3.