Successful Implementation of Electronic Trauma Documentation in a Level III Trauma Center- It Can Be Done!

摘要

An interdisciplinary team developed and implemented an electronic process to document care provided to patients who have sustained traumatic injuries. The goal of the team was to integrate the paper Emergency Department (ED) trauma flow sheet into the electronic health record (EHR) ensuring timely access by all system users to trauma documentation and enabling improved data abstraction and quality of trauma documentation. A willingness to spend the time on the ground work and develop a hands-on, case-based educational approach resulted in a positive outcome that improved trauma documentation, enhanced data extraction capability, and allowed all end users to visualize care in the ED.