1. Comparison of paper and electronic documentation for trauma activations in a pediatric trauma center.
- Author
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Kieffer JC, Thompson A, Elwell S, and DePiero A
- Subjects
- Adolescent, Child, Child, Preschool, Documentation standards, Documentation statistics & numerical data, Female, Humans, Infant, Infant, Newborn, Male, Retrospective Studies, Video Recording, Data Accuracy, Documentation methods, Electronic Health Records standards, Electronic Health Records statistics & numerical data, Emergency Service, Hospital standards, Emergency Service, Hospital statistics & numerical data, Paper, Trauma Centers standards, Trauma Centers statistics & numerical data, Wounds and Injuries diagnosis, Wounds and Injuries therapy
- Abstract
Background: There are limited data on the accuracy of documentation of trauma activations in the electronic medical record (EMR) compared with a paper chart. Our primary objective was to compare the accuracy of documentation between a paper chart and EMR in pediatric trauma., Methods: We studied video recordings of trauma activations at a level 1 pediatric trauma center. These videos were reviewed, and data points collected were used to compare accuracy of documentation in the paper chart and EMR., Results: We reviewed 106 videos with 1614 data points collected. Of those, 805 data points were compared with their corresponding paper chart with 710 data points correctly documented (88.2%). The remaining 809 data points were compared with their corresponding electronic documentation after implementation of the EMR with 681 data points being correctly documented (84.2%). Overall, we found that paper documentation was significantly more accurate than the EMR (p = 0.019). When analyzed in subcategories of pre-arrival information, primary and secondary survey, and interventions, paper documentation was found to be significantly more accurate than the EMR for components of the primary and secondary survey (87.3% vs. 80.4%, p = 0.001). There was no significant difference in accuracy of documentation between paper and EMR for pre-arrival information (88.1% vs. 89.4%) or interventions (90.3% vs. 92%)., Conclusion: Documentation of trauma activations is overall more accurate using a paper chart than EMR. Although documentation was accurate for most categories using both a paper chart and EMR, we found significantly less accuracy in documentation of the primary and secondary survey in the EMR., Competing Interests: Declaration of Competing Interest The authors have no disclosures or conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)
- Published
- 2021
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