A New Chart to Assist with Advanced Trauma Life Support

Palmer, Ian; Baskett, F; McCabe, Sean Esteban

doi:10.1136/jramc-138-03-03

Cited by 7 publications

(3 citation statements)

References 10 publications

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“…In one study a structured questionnaire that formed part of each woman’s notes at ante‐natal booking provided much better information with particular emphasis on risk factor identification than did free form clerking[5]. In another, Palmer et al have demonstrated similar advantages in the acute trauma setting where templates reduce the likelihood of overlooking life‐threatening illnesses[6].…”

Section: Making Protocols Stickmentioning

confidence: 99%

Clinical Protocols Are Key to Quality Health Care Delivery

Heymann

1994

International J Health Care QA

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The use of clinical protocols allows health care providers to offer appropriate diagnostic treatment and care services to patients, variance reports to purchasers and quality training to clinical staff. Such protocols provide a locally agreed standard to which clinicians and the organization can work and against which they can be audited. By embedding protocols into patients' records and reporting by exception, the use of protocols may help to tackle a raft of other issues successfully such as the reduction in junior doctors' hours, and the facilitation of shared care. It may also bolster the medico-legal robustness of the health care delivered. If the protocols are sufficiently detailed, costing, coding and other resource usage information can flow directly from the clinical records. Such benefits may be maximized by using protocols within the framework of an electronic patient record system.

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Section: Making Protocols Stickmentioning

confidence: 99%

Clinical Protocols Are Key to Quality Health Care Delivery

Heymann

1994

International J Health Care QA

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“…Exemplary for the actual situation of trauma documentation is a study by Hamill et al [13] from the year 2000, in which the authors examined the impact of a standardized trauma form for documentation in cases of major trauma compared with the routinely used formless trauma documentation. The conclusion of Palmer et al [14] from the year 1992, that "only little attention is payed to documentation", still seems to be into effect, and Zintl et al [3] summarize the actual situation regarding the overall quality of trauma data re- Within the field of "on-line" data acquisition, various research groups partly favor totally different reporting techniques: common are conventional, i.e., handwritten forms, mostly without any relation to an electronic data management system, even retrospectively [3,15]. Compared with this, the audio- [9] and the videodocumentation technique [6][7][8] have to be emphasized.…”

Section: Discussionmentioning

confidence: 99%

Improved Data Quality by Pen Computer–Assisted Emergency Room Data Recording Following Major Trauma

Helm¹,

Kulla²,

Hauke³

et al. 2005

Eur J Trauma

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European Journal of Trauma Ab stractBackground: Quality management is a decisive factor in optimizing the treatment of major trauma cases. In this context high-quality data recording is of fundamental importance. Regarding data quality, "on-line" -especially pen computer-based -recording techniques are favored. Up to now, however, there is no study really proving a higher quality of emergency room (ER) data by use of such a technique in comparison with a paper-based technique. Material and Methods: In all major trauma cases a standardized ER data recording, using "TraumaWatch", was performed; the study collective was divided into two subgroups: the "pen" collective using a pen computer-based technique and the "paper" collective using a paper-based technique. Data quality was defined as level of data completeness. Results: A total of 207 major trauma cases underwent ER management. There was no statistically significant difference between the "pen" (n = 135) and the "paper" collective (n = 72) regarding gender, age, mechanism of injury, injury severity, and duration of ER management. There was no correlation between degree of injury severity and level of dataset completeness. Total dataset completeness was significantly higher within the "pen" collective (93.6% vs. 82.5%; p < 0.01); the same applies to the core dataset (Utstein style) completeness (97.3% vs. 91.3%; p < 0.01). Conclusion: Defining data quality as level of data completeness, a pen computer-based recording technique, which allows easy and fast -real-time -data acquisition during ER management, seems to be superior to the conventional paper-based technique.

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“…Templates have long been used for clinical data collection [52][53][54] and in EHR documentation systems. 14,26,28,38,42,45,[55][56][57][58][59][60] Similar to the description of ''documentation templates'' in electronic medical records by Yamazaki et al, 55,61 the VUMC CNCT templates consisted of easily read and edited plain-text files marked up with simple (XML-like) tags for document sections (header, body, footer); prompts for run-time enduser input; and markers for potential sites of insertion, formatting, and conditional logic.…”

Section: Vumc Cnct Implementation Historymentioning

confidence: 99%

Experience in Implementing Inpatient Clinical Note Capture via a Provider Order Entry System

Rosenbloom

Grande²,

Geissbühler³

et al. 2004

Journal of the American Medical Informatics Association

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Care providers' adoption of computer-based health-related documentation ("note capture") tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool-a concept that may seem counterintuitive to some.

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A New Chart to Assist with Advanced Trauma Life Support

Cited by 7 publications

References 10 publications

Clinical Protocols Are Key to Quality Health Care Delivery

Clinical Protocols Are Key to Quality Health Care Delivery

Improved Data Quality by Pen Computer–Assisted Emergency Room Data Recording Following Major Trauma

Experience in Implementing Inpatient Clinical Note Capture via a Provider Order Entry System

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