(HealthDay News) — Electronic documentation produces more complete records of pediatric trauma resuscitations than paper documentation, according to a study published in the January issue of the Journal of Emergency Nursing.
Carla Coffey, R.N., from the Nationwide Children’s Hospital in Columbus, Ohio, and colleagues compared a random sample of 200 trauma resuscitations documented by paper with a random sample of 200 trauma resuscitations documented electronically. The authors compared the presence and absence of 11 key data elements for each trauma resuscitation.
The researchers found that five key elements were more frequently captured by electronic documentation: time of team activation (P < 0.00), primary assessment (P < 0.036), arrival time of attending physician (P < 0.026), intravenous fluid volume in the emergency department (P < 0.036), and disposition (P < 0.00). Volume of intravenous fluids administered prior to arrival was the one data element more frequently recorded in the paper documentation (P < 0.00). There was no statistical difference in documentation for the other five key elements: vital signs, treatment by emergency medical personnel, arrival time in emergency department, and level of trauma alert activation.
“Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations,” the authors write.