Improving Trauma Documentation in the Emergency Department

Adequate and complete trauma documentation continues to be a struggle for many health care institutions. A recently accredited Pennsylvania trauma center shared its struggles and successes in the improvement of trauma documentation in the emergency department. Such interventions included education for new nurses and ongoing education, a user-friendly trauma flow sheet, and a peer review process. Fewer documentation deficiencies were seen after the implementation of such interventions. Variables found to have a positive impact on these results were recognition of patients with low severity injuries, the peer review process, and emergency department administrative involvement.