Comparison of paper and electronic documentation for trauma activations in a pediatric trauma center.

BACKGROUND

There are limited data on the accuracy of documentation of trauma activations in the electronic medical record (EMR) compared with a paper chart. Our primary objective was to compare the accuracy of documentation between a paper chart and EMR in pediatric trauma.

METHODS

We studied video recordings of trauma activations at a level 1 pediatric trauma center. These videos were reviewed, and data points collected were used to compare accuracy of documentation in the paper chart and EMR.

RESULTS

We reviewed 106 videos with 1614 data points collected. Of those, 805 data points were compared with their corresponding paper chart with 710 data points correctly documented (88.2%). The remaining 809 data points were compared with their corresponding electronic documentation after implementation of the EMR with 681 data points being correctly documented (84.2%). Overall, we found that paper documentation was significantly more accurate than the EMR (p = 0.019). When analyzed in subcategories of pre-arrival information, primary and secondary survey, and interventions, paper documentation was found to be significantly more accurate than the EMR for components of the primary and secondary survey (87.3% vs. 80.4%, p = 0.001). There was no significant difference in accuracy of documentation between paper and EMR for pre-arrival information (88.1% vs. 89.4%) or interventions (90.3% vs. 92%).

CONCLUSION

Documentation of trauma activations is overall more accurate using a paper chart than EMR. Although documentation was accurate for most categories using both a paper chart and EMR, we found significantly less accuracy in documentation of the primary and secondary survey in the EMR.