960 Referral Documentation in Orthopaedic Trauma

Abstract

Abstract Aim We aimed to measure and improve documentation and decision making for on-call Orthopaedic Trauma referrals. Method Documentation for all referrals to the Orthopaedic Trauma Service, at a major urban trauma centre, in Scotland, over a defined period was reviewed. The audit conducted between February 2020 and November 2021. Documentation was scored. Two further audit cycles were performed after the introduction of an electronic “contact note” system. Results There was a dramatic improvement between cycle 1 and cycle 3 of available documentation 76% versus 98%. Documentation was available on the day of referral for 60% of cases reviewed by cycle 3 versus 30% for cycle 1; 98% complete documentation was available by day 2 during cycle 3. The system was rated high satisfactory by 90%% of users. Conclusions Complete documentation was more widely and more quickly available after the introduction of an electronic note keeping system. The system was user friendly and rated high satisfactory. We believe the system improved patient safety.