2.50
Hdl Handle:
http://hdl.handle.net/10755/162406
Type:
Presentation
Title:
Implementing a Computerized Documentation System in a Trauma Bay
Abstract:
Implementing a Computerized Documentation System in a Trauma Bay
Conference Sponsor:Emergency Nurses Association
Conference Year:2010
Author:Schmidt, Leigh Anne, RN, BSN
P.I. Institution Name:Hospital of the University of Pennsylvania
Title:Nurse Manager Emergency Department
Contact Address:3400 Spruce Street Silverstein Ground, Philadelphia, PA, 19104, USA
Contact Telephone:215-349-8763
Co-Authors:Rhonda Holmstrom, RN, BSN, CEN
[ENA Annual Conference - Evidence-based Practice Presentation]
Purpose: "Trauma care providers and trauma systems have a variety of sophisticated technologies and infrastructures available to care for critically injured trauma patients. However, when it comes to patient tracking and documentation, many trauma care providers resort to the pencil and paper methods (Eastes, 2001)." Using current advances in technology we developed an electronic medical record for the initial trauma resuscitation for 100% of trauma activations.

Design: Quality assurance project

Setting: This project was conducted at a Level I trauma center, urban setting.

Participants: ED Information Systems Staff, ED staff, Trauma Program Manager, Trauma PI Coordinator, Trauma Registrars, Trauma Physicians, ED Physicians, ED Leadership, & Revenue Cycle Analyst.

Methods: On the basis that trauma documentation is highly regulated and requires review by multiple interdisciplinary and regulatory groups the decision was made to move to an electronic medical record to ensure all required documentation was captured. The ED staff in conjunction with the trauma team met to discuss the required aspects of documentation by all regulatory bodies. Mutually agreed upon goals of the new system were to increase the capture of billing elements, increase legibility, increase time efficiency of providers, increase the availability of the trauma record to multiple users for documentation and review, increase capture of clinical events and improve documentation overall. The team of the above participants was assembled and met every other week. The initial build for the Traumatrac system was completed by the ED IS team. After the initial build of the electronic documentation the testing and re-configuration was controlled by the end users. This system remains highly adaptable with added prompts to ensure that all documentation fields are complete. On-site IS support is available to make immediate modifications and help the end user improve compliance 24 hours a day. Some recent enhancements include the ability to link the current trauma visit to previous health system encounters and health care clinics having access to review trauma documentation at follow up visits.

Results: Improved communication and patient handoff between disciplines and departments was developed. The multi-disciplinary partnership developed to implement the computerized documentation system has insured the success and continued improvement of the new system.

Implications: The electronic medical record for trauma resuscitations has improved the level of documentation. We have shown an increase in many documentation PI indicators such as: vital signs, temperature, pain assessment, warming measures initiated and I & O's with a high degree of procedure time accuracy. The system allows for multiple team members to document and review simultaneously.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleImplementing a Computerized Documentation System in a Trauma Bayen_GB
dc.identifier.urihttp://hdl.handle.net/10755/162406-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Implementing a Computerized Documentation System in a Trauma Bay</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2010</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Schmidt, Leigh Anne, RN, BSN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Hospital of the University of Pennsylvania</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Nurse Manager Emergency Department</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">3400 Spruce Street Silverstein Ground, Philadelphia, PA, 19104, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">215-349-8763</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">leighann.schmidt@uphs.upenn.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Rhonda Holmstrom, RN, BSN, CEN</td></tr><tr><td colspan="2" class="item-abstract">[ENA Annual Conference - Evidence-based Practice Presentation] <br/>Purpose: &quot;Trauma care providers and trauma systems have a variety of sophisticated technologies and infrastructures available to care for critically injured trauma patients. However, when it comes to patient tracking and documentation, many trauma care providers resort to the pencil and paper methods (Eastes, 2001).&quot; Using current advances in technology we developed an electronic medical record for the initial trauma resuscitation for 100% of trauma activations. <br/><br/>Design: Quality assurance project<br/><br/>Setting: This project was conducted at a Level I trauma center, urban setting. <br/><br/>Participants: ED Information Systems Staff, ED staff, Trauma Program Manager, Trauma PI Coordinator, Trauma Registrars, Trauma Physicians, ED Physicians, ED Leadership, &amp; Revenue Cycle Analyst.<br/><br/>Methods: On the basis that trauma documentation is highly regulated and requires review by multiple interdisciplinary and regulatory groups the decision was made to move to an electronic medical record to ensure all required documentation was captured. The ED staff in conjunction with the trauma team met to discuss the required aspects of documentation by all regulatory bodies. Mutually agreed upon goals of the new system were to increase the capture of billing elements, increase legibility, increase time efficiency of providers, increase the availability of the trauma record to multiple users for documentation and review, increase capture of clinical events and improve documentation overall. The team of the above participants was assembled and met every other week. The initial build for the Traumatrac system was completed by the ED IS team. After the initial build of the electronic documentation the testing and re-configuration was controlled by the end users. This system remains highly adaptable with added prompts to ensure that all documentation fields are complete. On-site IS support is available to make immediate modifications and help the end user improve compliance 24 hours a day. Some recent enhancements include the ability to link the current trauma visit to previous health system encounters and health care clinics having access to review trauma documentation at follow up visits.<br/><br/>Results: Improved communication and patient handoff between disciplines and departments was developed. The multi-disciplinary partnership developed to implement the computerized documentation system has insured the success and continued improvement of the new system.<br/><br/>Implications: The electronic medical record for trauma resuscitations has improved the level of documentation. We have shown an increase in many documentation PI indicators such as: vital signs, temperature, pain assessment, warming measures initiated and I &amp; O's with a high degree of procedure time accuracy. The system allows for multiple team members to document and review simultaneously.<br/></td></tr></table>en_GB
dc.date.available2011-10-27T10:27:40Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:27:40Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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