Do preformatted charts improve doctors' documentation in a rural hospital emergency department? A prospective trial.

AIM

To determine if the introduction of preformatted patient record charts improved documentation by doctors in a rural emergency department.

METHODS

All medical records of patients who were discharged from the emergency department were collected and analysed for a period of two weeks (control). The preformatted patient charts were then introduced for a further two weeks, and analysed for the presence or absence of key content items

RESULTS

After exclusions, 137 control charts and 96 preformatted charts were collected and analysed. It was found that, overall, there was a significant improvement in the number of the key items documented (p<0.005). There was a trend towards improvement in four parameters, but for three other key content items, there was a nonsignificant decline in documentation standards.

CONCLUSION

A structured proforma does improve documentation. However, the improvement is small and further studies are required before use of preformatted patient records for the undifferentiated emergency department patients can be recommended.