USE OF A PRO FORMA FOR HEAD-INJURIES IN THE ACCIDENT AND EMERGENCY DEPARTMENT - THE WAY FORWARD

The aim of this study was to assess the quality of documentation of he ad-injured patients seen in three accident and emergency (A&E) departm ents using a specially designed head injury pro forma. A 4-week prospe ctive study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, o ne for young children and babies, the other for older children and adu lts). The main outcome measures were the degree of completion of the p ro forma and questionnaire responses from receptionists, nurses and do ctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head inj ury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvement s were made, and the majority of staff felt it should be introduced pe rmanently into the A&E department. Concern about its use in cases of v ery minor head injury and multiple injuries were raised. As well as im proved documentation, the pro forma facilitates the process of audit a nd may have an important role to play in information technology and co mputers in the future.