LAUSR

The BSSH standards of care in hand trauma emphasise the importance of accurate and comprehensive documentation. This quality improvement project aimed to evaluate whether an electronic proforma could improve documentation rates in hand trauma. This prospective, closed-loop audit involved two cycles of seven consecutive days. Outcomes were evaluated against BSSH standards of care using 15 data points. Pre-audit, a bespoke proforma was piloted in the hand trauma clinic and revised following feedback. In the first cycle (‘Loop 1’), documentation in the hand trauma clinic was compared with that of the acute take, where clinicians were still using free text. The second cycle (‘Loop 2’) compared documentation pre- and post-introduction of the proforma within the acute take setting. Categorical data were interrogated using the χ2 test with significance set at p < 0.05. 122 patients were included in the Loop 1 dataset. Free text clerking quality varied between clinician groups (e.g., surgical trainees significantly outperformed advanced nurse practitioners in 5/15 data points); however, some data points were universally poorly documented. 99 patients were included in the Loop 2 dataset. There was excellent uptake of the proforma in both acute take (95%) and hand trauma clinic (100%) settings. Statistically significant improvements were seen in 11/15 data points following the introduction of the proforma. This project demonstrates that the introduction of a hand trauma clerking proforma led to significant improvements in documentation quality. The proforma has now been developed into a Trust-wide ClinDoc which brings additional benefits in terms of research, audit and service evaluation.