Quality Of Documentation Research Articles

Use of an ambient artificial intelligence tool to improve quality of clinical documentation

BackgroundElectronic health records (EHRs) have contributed to increased workloads for clinicians. Ambient artificial intelligence (AI) tools offer potential solutions, aiming to streamline clinical documentation and alleviate cognitive strain on healthcare providers. ObjectiveTo assess the clinical utility of an ambient AI tool in enhancing consultation experience and the completion of clinical documentation. MethodsOutpatient consultations were simulated with actors and clinicians, comparing the AI tool against standard EHR practices. Documentation was assessed by the Sheffield Assessment Instrument for Letters (SAIL). Clinician experience was measured through questionnaires and the NASA Task Load Index. ResultsAI-produced documentation achieved higher SAIL scores, with consultations 26.3% shorter on average, without impacting patient interaction time. Clinicians reported an enhanced experience and reduced task load. ConclusionsThe AI tool significantly improved documentation quality and operational efficiency in simulated consultations. Clinicians recognised its potential to improve note-taking processes, indicating promise for integration into healthcare practices.

145 Didactic Instruction’s Impact Upon Medicolegal Quality of Radiation Oncology Resident Physician Documentation

145 Didactic Instruction’s Impact Upon Medicolegal Quality of Radiation Oncology Resident Physician Documentation

A review on quality management system in laboratory testing

A Laboratory Quality Management System (LQMS) refers to a set of policies, procedures, and practices implemented in a laboratory to ensure consistent quality and accuracy in its operations. Continuous improvement of laboratory quality service is vital to ensure accuracy, reliability, and timeliness of laboratory results. Implementation of the quality management system is an effective way of monitoring and assuring laboratory quality service. Various standards and regulations outline specific requirements for implementing a Quality Management System (QMS) in a laboratory environment, such as ISO 15189:2022, ISO 17025:2017, and FDA 42 CFR Part 493. These standards provide guidelines and criteria for laboratory processes, including testing, calibration, documentation, personnel competency, and overall quality control. This article will discuss the applicable standards and legislation, the 12 essential elements of laboratory QMS, and the role of QMS software in a laboratory environment. The objective of this study is to assess the impact of laboratory quality management system implementation on improving quality laboratory service.

Structural and Process Factors Influencing Documentation Practice in Private and Public Labour Wards of Parirenyatwa Maternity Hospital, Zimbabwe

Background: Documentation is crucial for evidence-based nursing. Proper documentation ensures effective communication and quality patient care, while poor documentation compromises care. This study compared structural and process factors affecting documentation quality and patient outcomes in private and public labor wards at Parirenyatwa Mbuya Nehanda Maternity Hospital (MNMH). Methods: A multiple methods approach was used. A total of 177 records were assessed for quality documentation, and 10 midwives were observed on practice documentation. Additionally, 116 interviews were conducted with midwives to elicit information on documentation practices. Data was collected and quantitative data was analyzed using Statistical Package for Social Sciences version (SPSS version 20). Qualitative data was manually analysed and thematic analysis was used to generate codes and themes. Quantitative data was presented in tables, graphs, as frequencies and percentages while qualitative data was presented in narrative form. Results: With regards to structural factors, being in a public labour ward was significantly associated with increased the likelihood of higher nurse to patient ratio compared to being in a private labour ward (p=0.002). No process indicator was significantly associated with the type of labour. Those in the public labour ward were more likely to have complications and admitted in (Neonatal Intensive Care Unit) NICU (p=0.008). Conclusion: The study determined that there was poor documentation practice in both public and private labour wards. Though there was a high level of awareness of critical aspects of labour to document and the importance of documentation by midwives from both wards, this did not necessarily translate to practice. There is a need to also formulate standard operating protocols and guidelines to guide and standardize documentation at MNMH.

A new form of the medical record of a patient receiving medical care in inpatient conditions, in a day hospital as a criterion for the quality and safety of medical activity

Objective: to conduct a comparative analysis of the previously valid “Card” with a new form of “Card” filled in for patients receiving medical care in a hospital setting with the focus of the attention of practitioners on the new paragraphs of this document.Materials and methods: a comparative analysis of the medical record of an inpatient patient approved by the order of the Ministry of Health of the USSR dated October 4, 1980 was carried out. No. 1030 “On Approval of Forms of primary Medical Documentation of healthcare institutions” and the Medical record of a patient receiving medical care in inpatient conditions, in a Day hospital, approved by the Order of the Ministry of Health of the Russian Federation dated August 5, 2022 No. 530n “On Approval of Unified Forms of medical documentation used in medical organizations providing medical care in inpatient conditions, in the conditions of the day hospital and the procedures for their management”.Results: based on the results of the study of two forms of “Cards”, the advantages of the new form have been established, which improve the quality of medical documentation and, as a result, taking into account the fact that the ECMP is carried out according to medical documentation, lead to a reduction in the risks of imposing financial sanctions on medical organizations during the relevant examinations. In particular, a number of shortcomings of the new form of the “Map” are indicated, requiring additional study and discussion with possible additions in the future.Conclusions: the relevance of the examination of the quality of medical care, which, as a rule, is carried out according to the medical documentation of completed cases, is reflected. It is noted that the correct filling in of all the provided graphs and lines will minimize the number of defects in the registration of medical documentation, which in turn will reduce the financial sanctions imposed on medical organizations during the ECMP.

A human centered design approach to define and measure documentation quality using an EHR virtual simulation.

Electronic health record (EHR) documentation serves multiple functions, including recording patient health status, enabling interprofessional communication, supporting billing, and providing data to support the quality infrastructure of a Learning Healthcare System. There is no definition and standardized method to assess documentation quality in EHRs. Using a human-centered design (HCD) approach, we define and describe a method to measure documentation quality. Documentation quality was defined as timely, accurate, user-centered, and efficient. Measurement of quality used a virtual simulated standardized patient visit via an EHR vendor platform. By observing and recording documentation efforts, nurse practitioners (NPs) (N = 12) documented the delivery of an Age-Friendly Health System (AFHS) 4Ms (what Matters, Medication, Mentation, and Mobility) clinic visit using a standardized case. Results for timely documentation indicated considerable variability in completion times of documenting the 4Ms. Accuracy varied, as there were many types of episodes of erroneous documentation and extra time in seconds in documenting the 4Ms. The type and frequency of erroneous documentation efforts were related to navigation burden when navigating to different documentation tabs. The evaluated system demonstrated poor usability, with most participants scoring between 60 and 70 on the System Usability Scale (SUS). Efficiency, measured as click burden (the number of clicks used to navigate through a software system), revealed significant variability in the number of clicks required, with the NPs averaging approximately 13 clicks above the minimum requirement. The HCD methodology used in this study to assess the documentation quality proved feasible and provided valuable information on the quality of documentation. By assessing the quality of documentation, the gathered data can be leveraged to enhance documentation, optimize user experience, and elevate the quality of data within a Learning Healthcare System.

2317 Geriatrician-led perioperative services: an example of value-based care

Abstract Background Perioperative services must adapt to the needs of an increasingly older surgical population. Perioperative medicine for Older People undergoing Surgery (POPS) services integrate geriatric medicine teams into surgical pathways to provide quality and cost-effective medical care. This project aims to examine value-based outcomes (clinical and financial impact) of embedding a POPS service at a district general hospital. Methods Following a period of implementation on an acute Trauma and Orthopaedic (T&O) ward, a two-week pilot was undertaken. All emergency fragility fracture admissions aged over 65 years with Clinical Frailty Scores (CFS) of ≥5 were included. Patients with hip fractures were excluded. The POPS service provided medical consultation, medicine rationalisation, proactive treatment escalation planning and shared decision making, as well as leading multidisciplinary team meetings. Outcome metrics: geriatric medicine consults, medical emergency team (MET)/cardiac arrest calls, staff/patient satisfaction and clinical coding. The REDUCE trial cost calculator was used to estimate savings. Results 35 patients were included, mean age 84 years, mean CFS score 7. Ward MET calls and cardiac arrest calls were reduced from a weekly average of 2.5 to 0, and weekly referrals to geriatric medicine reduced from 3 to 0. Experience-based design surveys identified thematic improvements relating to leadership, communication, dignity and respect. Improved quality of documentation resulted in the comorbidity score tariff increasing from £3325 to £6096 per patient. For services introduced by POPS including Comprehensive Geriatric Assessment and delirium assessments, the REDUCE trial cost calculator estimated an additional saving of £2926 per patient totalling hospital savings of £2 million per year (for an estimated 700 patients per year). Conclusion Implementation of a POPS service at a district general hospital can lead to cost savings, improved patient and staff experience, and improved clinical outcomes within a sustainable workforce model.

2254 Improving the quality and breadth of advance care planning discussions on gerontology wards in an acute London trust

Abstract Introduction Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust. Method A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test. Results ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient. Conclusion The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.

Effectiveness of a Structured Trauma Template in Improving Clinical Examination Accuracy in Maxillofacial Trauma: A Prospective Study

Study Design Prospective pre-post study. Objective 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. Methods 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. Results 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 P = .001, and referral with P = .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 P = .001, and extraocular muscle restriction with P = .004. Conclusions 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.

Lost in translation: Unveiling medical students' untold errors of medical history documentation.

The accurate documentation of a medical history interview is an important goal in medical education. As students' documentation of medical history interviews is mostly decentralised on the wards, a systematic assessment of documentation quality is missing. We therefore evaluated the extent of details missed in students' medical history reports in a standardised setting. In this prospective, observational study, 123 of 380 students (32.4%) participated in an Objective Structured Clinical Examination (OSCE) regarding history taking and documentation. Based on the interviews and nine deductively selected main categories, a categorical system was established using a summarising qualitative content analysis. The items in the transcripts (defined as ground truth) and in students' reports were labelled and assigned to the correct subcategory. The ground truth and students' reports were compared to quantify students' documentation completeness. Next to the nine deductively selected main categories, 61 subcategories were defined. A total of 8943 items were labelled in the 123 interview transcripts (ground truth), compared with 5870 items labelled in students' reports (65.6% completeness of students' reports compared with ground truth). The main category personal details overlapped with 94.2% between students' report and ground truth incontrast to the main category with the highest discrepancy, allergy, with 41.1% overlap. Pertinent negative items and non-numerical quantifications were often missed. Medical students show incomplete documentation of medical history interviews. Therefore, accurate documentation should be taught as an important goal in medical education.

An ontology-based tool for modeling and documenting events in neurosurgery

BackgroundIntraoperative neurophysiological monitoring (IOM) plays a pivotal role in enhancing patient safety during neurosurgical procedures. This vital technique involves the continuous measurement of evoked potentials to provide early warnings and ensure the preservation of critical neural structures. One of the primary challenges has been the effective documentation of IOM events with semantically enriched characterizations. This study aimed to address this challenge by developing an ontology-based tool.MethodsWe structured the development of the IOM Documentation Ontology (IOMDO) and the associated tool into three distinct phases. The initial phase focused on the ontology’s creation, drawing from the OBO (Open Biological and Biomedical Ontology) principles. The subsequent phase involved agile software development, a flexible approach to encapsulate the diverse requirements and swiftly produce a prototype. The last phase entailed practical evaluation within real-world documentation settings. This crucial stage enabled us to gather firsthand insights, assessing the tool’s functionality and efficacy. The observations made during this phase formed the basis for essential adjustments to ensure the tool’s productive utilization.ResultsThe core entities of the ontology revolve around central aspects of IOM, including measurements characterized by timestamp, type, values, and location. Concepts and terms of several ontologies were integrated into IOMDO, e.g., the Foundation Model of Anatomy (FMA), the Human Phenotype Ontology (HPO) and the ontology for surgical process models (OntoSPM) related to general surgical terms. The software tool developed for extending the ontology and the associated knowledge base was built with JavaFX for the user-friendly frontend and Apache Jena for the robust backend. The tool’s evaluation involved test users who unanimously found the interface accessible and usable, even for those without extensive technical expertise.ConclusionsThrough the establishment of a structured and standardized framework for characterizing IOM events, our ontology-based tool holds the potential to enhance the quality of documentation, benefiting patient care by improving the foundation for informed decision-making. Furthermore, researchers can leverage the semantically enriched data to identify trends, patterns, and areas for surgical practice enhancement. To optimize documentation through ontology-based approaches, it’s crucial to address potential modeling issues that are associated with the Ontology of Adverse Events.

Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs

BackgroundElectronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality.MethodsPatients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality.ResultsEncounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points.ConclusionsAmong outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.

Integrated project delivery enablers to enhance conventional project delivery toward improving design documentation quality

PurposeThe purpose of this study was to identify specific enablers intrinsic to integrated project delivery (IPD) that can be adapted into the conventional project delivery (CPD) approach to enhance the quality of design documentation produced under the CPD within the Ghanaian construction industry.Design/methodology/approachThe study employed questionnaires and semi-structured interviews for data collection. The sample size was 235 responses for questionnaires while 15 participants were interviewed. The survey instrument was piloted with industry professionals to ensure validity. IBM SPSS was used to analyze quantitative data by determining frequencies, percentages, correlation and regression, while content analysis was used on qualitative data with the aid of QSR Nvivo software.FindingsKey findings include the need to adapt the early involvement of key participants for collaborative design input, tie individual success to overall project success with incentives and establish shared accountability for design errors and encourage open communication.Practical implicationsAdapting IPD enablers into the CPD approach would ensure higher-quality design documentation and more efficient project delivery. This has the potential to improve project outcomes, reduce errors, and foster better collaboration among stakeholders.Originality/valueThis study is the first of its kind to identify specific enablers inherent in IPD that can be adapted into the CPD approach to improve the quality of design documentation within the Ghanaian construction industry.

182 Keyboard Warriors Sparking a Digital Renaissance: The New Frontier in Traumatology Documentation

Abstract Aim To align clinical records with the high-caliber examinations performed, specifically targeting the vague "Neurovascularly Intact" or 'NVI' term. By enhancing record accuracy, the initiative sought to improve patient recovery tracking and provide robust medicolegal documentation, all while easing the workload of on-call doctors. Method Our audit evaluated the initial clerkings by on-call doctors for trauma patients, analyzing 59 records (n=59) against NICE and BOAST standards pre-intervention. To rectify the prevalent use of 'NVI', we introduced an autotext template, activated by 'NVIL' or 'NVIU', which auto-populates with a detailed assessment while allowing clinician customization. Post-intervention, we examined a further 57 records (n=57) to assess the impact on documentation quality. Results Before intervention compliance was poor: Nerve listed (11.86%), motor tested using MRC grading scale (8.47%), sensory tested (22.03%), blood vessel listed (18.64%), CRT tested (18.64%), and limb color recorded (6.78%). After intervention, compliance increased: nerve listed (91.23%), motor function (96.49%), sensory (96.49%), blood vessels (92.98%), CRT (94.74%), and limb color (82.46%). Documentation of 'NVI' reduced from 55.93% to 3.51%. Fisher's Exact Test with post hoc Bonferroni correction shows results were statistically significant (P<0.05). Conclusions This audit heralds an innovative breakthrough by adeptly leveraging system one thinking through technology to enhance documentation in the NHS. By introducing the autotext template, we've elevated documentation precision, strengthened medicolegal safeguards, and shifted the focus from service-dominated tasks to allow time for physician professional growth.This advancement is a significant stride towards balancing the scales, emphasizing the importance of both patient outcomes and physician development in a system under pressure.

Improving the quality of newborn feeding documentation in an EHR using a mixed methods approach

IntroductionNewborn feeding is key to infant growth and survival. Accurate feeding documentation can inform care decisions and planning of care. A nutritional dashboard is available within the Electronic Health Record (EHR) which accumulates feeding data in a graphical display. PurposeTo improve the quality of newborn feeding documentation for post-natal ward babies and babies in the Neonatal Intensive Care Unit (NICU). Designand Methods: A multidisciplinary end user expert group (n = 38) was established. Qualitative thematic analyses from this group were used to design new feeding data entry and review elements. Quantitative pre-post design was used to assess feeding documentation for both post-natal ward baby charts (n = 134) and NICU baby charts (n = 188). Descriptive statistics and Pearson's chi-square were used to assess pre-post differences and statistical significance. The use of a nutritional dashboard was assessed using system audit logs and analyzed using Poisson regression testing. ResultsPost-natal ward babies had improvements in structured feeding documentation by 91.6% (from 17.9% to 34.3%) (p = 0.031). NICU data feeding documentation improved by 25% (from 72.3% to 90.4%) (p = 0.001). Use of the nutritional dashboard however reduced in the post period. ConclusionThis study has positively demonstrated improvements in the quality of newborn feeding documentation within the patient's EHR can be achieved through a collaborative multidisciplinary approach optimising EHR design. Practice implicationsThe benefit of a multidisciplinary approach to EHR design is paramount to promoting superior quality data entry compliant with individual workflows.

113 R-E-S-P-E-C-T: A Closed-Loop Audit Increasing the Quality of ReSPECT Documentation in a Tertiary Surgical Centre in the United Kingdom

113 R-E-S-P-E-C-T: A Closed-Loop Audit Increasing the Quality of ReSPECT Documentation in a Tertiary Surgical Centre in the United Kingdom

Migration of Midwifery Care Documentation to Medical Records

Medical records are the key to documenting services for health workers who carry out independent practice, good documentation greatly affects the fulfillment of administrative aspects, legal aspects for midwives and patients and provides convenience in maintaining the quality of care documentation to patients. Medical records are very important for health care facilities including Independent Midwife Practices. The function of medical records is to record all health services that have been provided to patients in order to support the improvement of service quality. this study is to implement integrated midwifery care documentation using medical records. The purpose of this study was to implement integrated midwifery care documentation using medical records. This research is an RnD (Research and Development) study with a case study approach. Researchers conducted a data collection process with FGDs. The research was conducted in April-September 2023 at PMB Ummu Hani Bantul Yogyakarta. The object is the recording form that has been implemented. The data validation process used source and technical triangulation. The physical aspect of each form is A4 in size with a weight of 70mg, the paper used for the medical record folder is F4, glossy with cream-colored paper type ivory 260gram. The content aspect includes the division of data items, grouping of data, sequent and how to fill in based on the woman's life cycle, namely grouping the contents for data on pregnant women, maternity, postpartum and children. Obstetric documentation has used integrated documentation from pregnancy to postpartum and child growth and development which has become one document using a medical record folder.

Comparison of JavaScript Frontend Frameworks – Angular, React, and Vue

This research aims to evaluate JavaScript frontend frameworks by their performance and popularity to provide practitioners with guidance in making informed decisions when choosing frontend frameworks for their projects. For that purpose, three applications with the same features were built using three best-known JavaScript frontend frameworks: Angular, React, and Vue. Comparative analysis was employed to conduct the framework comparison using the content of the three applications. For performance evaluation, tools like PageSpeed Insights, WebPageTest, GTmetrix, Pingdom, Lighthouse, and Google Performance were used. In addition, the research also offers the overall comparison of JavaScript frameworks including documentation quality, ability to develop mobile applications, learning curve, built-in features, etc. The results indicate that while React is accepted as the most popular frontend framework, Vue is the one that offers the best performance. The research also compares JavaScript frameworks by specific features they offer such as state management and analyses the implications of these features to the development process. According to the results, these features have big implications on the development process and they are very important when we are making decisions on which framework we will choose for some project.

Automating surgical procedure extraction for society of surgeons adult cardiac surgery registry using pretrained language models.

Surgical registries play a crucial role in clinical knowledge discovery, hospital quality assurance, and quality improvement. However, maintaining a surgical registry requires significant monetary and human resources given the wide gamut of information abstracted from medical records ranging from patient co-morbidities to procedural details to post-operative outcomes. Although natural language processing (NLP) methods such as pretrained language models (PLMs) have promised automation of this process, there are yet substantial barriers to implementation. In particular, constant shifts in both underlying data and required registry content are hurdles to the application of NLP technologies. In our work, we evaluate the application of PLMs for automating the population of the Society of Thoracic Surgeons (STSs) adult cardiac surgery registry (ACS) procedural elements, for which we term Cardiovascular Surgery Bidirectional Encoder Representations from Transformers (CS-BERT). CS-BERT was validated across multiple satellite sites and versions of the STS-ACS registry. CS-BERT performed well (F1 score of 0.8417 ± 0.1838) in common cardiac surgery procedures compared to models based on diagnosis codes (F1 score of 0.6130 ± 0.0010). The model also generalized well to satellite sites and across different versions of the STS-ACS registry. This study provides evidence that PLMs can be used to extract the more common cardiac surgery procedure variables in the STS-ACS registry, potentially reducing need for expensive human annotation and wide scale dissemination. Further research is needed for rare procedural variables which suffer from both lack of data and variable documentation quality.

Unlocking the Potential of Underutilized Technology: A New Paradigm for Resident Doctor Efficiency.

Background The precision of clinical documentation in trauma and orthopaedic surgery is pivotal, given its profound implications on patient care and medicolegal risks. This study assessed the impact of an autotext template intervention on the adherence of clinical documentation to the neurovascular assessment standards set by the National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association Standards for Trauma (BOAST). Methods Conducted at a single hospital, this observational study comprised two phases: a retrospective analysis of clinical documentation for 56 fracture patients (n=56) followed by the implementation of an autotext template and subsequent analysis of a new cohort of 57 patients (n=57). The intervention aimed to enhance documentation quality in line with NICE and BOAST guidelines. Results Initial findings revealed a prevalent use of the nonspecific term "NVI" (neurovascularly intact), with only 8.5% (n=5) of pre-intervention documents adhering to detailed motor function assessments and a mere 6.8% (n=4) recording limb colour. Post-intervention analysis showed a significant improvement, with 91.23% (n=52) of documents listing nerves (P < 0.001) and 96.49% (n=55) adhering to motor function documentation using the Medical Research Council (MRC) grading scale (P < 0.001). Despite these advancements, the study acknowledges potential limitations such as the Hawthorne effect and the ongoing challenge of staff rotations. Conclusion The autotext template intervention markedly enhanced the adherence to neurovascular assessment documentation standards, as evidenced by the substantial increases in detailed parameter reporting and supported by statistically significant P-values. This advancement highlights the necessity of equipping clinicians with practical tools to uphold high documentation standards amidst challenging clinical conditions. Future investigations should focus on the long-term sustainability of these improvements across varying medical staff cohorts.