Pandey Akhilesh K, Pg Gigi, Rajanna Harshitha, Anil Abhishek, Kumar Pravin, Chugh Ankita
Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
Craniomaxillofac Trauma Reconstr. 2024 Dec;17(4):NP204-NP216. doi: 10.1177/19433875241272435. Epub 2024 Aug 6.
Prospective pre-post study.
Maxillofacial trauma presenting to the emergency department (ED) are often accompanied with complex concomitant injuries, thereby making thorough diagnosis and treatment plan quite an exacting task owing to the demanding conditions of the ED. The use of a structured maxillofacial trauma template helps in documenting the injuries comprehensively, aids in treatment planning, avoids medical negligence thereby improving the quality of care given to the patient. The study introduced a structured maxillofacial trauma template to improve the quality of the ED documentation.
A total of 220 patients were evaluated for the quality of their ED documentation from September 2023 till February 2024. The group A included 110 patients where complete medical documentation was done routinely on a blank A4 sized paper, group B included 110 patients where the documentation was done using the structured oral and maxillofacial trauma template. The ED notes were thoroughly evaluated by the 2 independent authors for record completeness and documentation rate of history and examination findings.
The introduction of trauma template demonstrated a significant improvement of 18.95 % in record completeness. Significant improvement was seen in documentation rate among the covariates like place of injury, time of evaluation, primary care given, wound classification, dento-alveolar injury, ophthalmic evaluation, nerve injury evaluation, comorbidities with = .001, and referral with = .03. The ophthalmic evaluation showed significant improvement among covariates (loss of visual acuity, reflexes, diplopia, enophthalmos, subconjunctival haemorrhage, chemosis, periorbital oedema, periorbital ecchymosis, ocular dystopia) with = .001, and extraocular muscle restriction with = .004.
The study demonstrated that the use of a structured oral and maxillofacial trauma template can significantly improve the quality of the ED documentation and contributes to better patient care in the ED.
前瞻性前后对照研究。
急诊科（ED）收治的颌面部创伤常伴有复杂的合并伤，由于急诊科条件苛刻，因此进行全面诊断和制定治疗方案是一项相当艰巨的任务。使用结构化的颌面部创伤模板有助于全面记录损伤情况，辅助治疗规划，避免医疗疏忽，从而提高给予患者的护理质量。本研究引入了结构化的颌面部创伤模板以提高急诊科文档记录的质量。
2023年9月至2024年2月期间，共对220例患者的急诊科文档记录质量进行了评估。A组包括110例患者，他们的完整医疗记录是在空白A4纸上常规完成的；B组包括110例患者，其记录是使用结构化的口腔颌面部创伤模板完成的。两名独立作者对急诊科记录进行了全面评估，以确定记录完整性以及病史和检查结果的记录率。
创伤模板的引入使记录完整性显著提高了18.95%。在诸如受伤部位、评估时间、初级护理、伤口分类、牙-牙槽损伤、眼科评估、神经损伤评估、合并症（P = 0.001）以及转诊（P = 0.03）等协变量的记录率方面有显著改善。眼科评估在协变量（视力丧失、反射、复视、眼球内陷、结膜下出血、结膜水肿、眶周水肿、眶周瘀斑、眼球异位）方面显示出显著改善（P = 0.001），眼外肌受限方面（P = 0.004）也有显著改善。
该研究表明，使用结构化的口腔颌面部创伤模板可显著提高急诊科文档记录的质量，并有助于在急诊科为患者提供更好的护理。
