RESUMO
INTRODUCTION: Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations. METHODS: The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n=200) was compared with a random sample of trauma resuscitations documented electronically (n=200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation. RESULTS: The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P<.00), primary assessment (94% vs 88%, P<.036), arrival time of attending physician (98% vs 93.5%, P<.026), intravenous fluid volume in the emergency department (94% vs 88%, P<.036), and disposition (100% vs 89.5%, P<.00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P<.00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation. DISCUSSION: Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations.
