Trauma form documentation in major trauma

Aims. To examine the impact of a standardised trauma form for documentation in cases of major trauma, a prospective study was undertaken. Methods. Records written by medical staff pertaining to the assessment and treatment of major trauma patients in the resuscitation room were scored ag ainst a panel of parameters derived from advanced trauma life support guide lines. Demographics, aetiology, trauma scores and trauma form were assessed using a questionnaire. me data were obtained from a trauma registry, des o f medical staff involved in major trauma to the Results. The trauma form was used in 53 of 69 (76.8%) consecutive cases of major trauma seen over a three month period. No significant differences exi sted in demographics, aetiology, trauma scores or outcome between form and formless groups. In the form group, a median of 44 of 51 (86.3%) relevant i nformation parameters were documented versus 32 of 51 (62.7%) in the formle ss group, p<0.0001. A positive approach to the trauma form was indicated by the questionnaire results. Conclusion. The use of a standardised form improves documentation in major trauma.