Electronic Documentation of Trauma Resuscitations at a Level 1 Pediatric Trauma Center

Abstract

Although many hospitals across the country have implemented an electronic medical record (EMR) for inpatient care, very few have successfully implemented an EMR for trauma resuscitations. Although there is evidence that the EMR improves patient safety, increases access to all care providers, increases workflow efficiency, and minimizes time spent on documenting thereby improving nursing care, the fast paced, complex nature of trauma resuscitations makes it difficult to implement such a system for trauma documentation. With the support of multiple disciplines with a variety of clinical knowledge, this article describes the design process that has led us to successful development and implementation of an EMR for documentation of trauma resuscitations.

Use of the Electronic Medical Record for Trauma Resuscitations

“…1 In an effort to create a completely paperless medical record for inpatient and outpatient care and to ensure that all providers have access to the trauma resuscitation record, Oregon Health & Science University (OHSU) began using the EMR for trauma resuscitations in December 2009. 1 In an effort to create a completely paperless medical record for inpatient and outpatient care and to ensure that all providers have access to the trauma resuscitation record, Oregon Health & Science University (OHSU) began using the EMR for trauma resuscitations in December 2009.…”

The painful truth

“…Home-grown computer documentation systems designed for specific specialties have been shown to be user friendly and to decrease documentation time. 10,11 However, the leading EMR companies design systems to be used across specialties, and specialty-specific data display and documentation are often lost. Advanced dictation software or the addition of a scribe to the rounding team may help documentation demands.…”

Reliability and validity of the checklist for early recognition and treatment of acute illness and injury as a charting tool in the medical intensive care unit

“…[ 20 ] Resuscitative practices nationally infrequently adopt electronic documentation tools due to the complexity of interventions, fast-paced nature and lack of dedicated resources for electronic charting. [ 21 ] In addition, the multiple data points in resuscitation practice potentially involve the use of multiple screens/portions of the EMR that might not be intuitive for practice. Using a single screen dashboard with all vital elements to resuscitation, the CERTAIN project aimed to circumvent this barrier.…”