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European Journal of Trauma and Emergency Surgery
Published in: European Journal of Trauma and Emergency Surgery 1/2022

Open Access 01-02-2022 | Original Article

The impact of a qualified medical documentation assistant on trauma room management

Authors: Benjamin Lucas, Sophie-Cecil Mathieu, Gerald Pliske, Wiebke Schirrmeister, Martin Kulla, Felix Walcher

Published in: European Journal of Trauma and Emergency Surgery | Issue 1/2022

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Abstract

Purpose

To improve quality of trauma room management, intra- and inter-hospital benchmarking are important tools. However, primary data quality is crucial for benchmarking reliability. In this study, we analyzed the effect of a medical documentation assistant on documentation completeness in trauma room management in comparison to documentation by physicians involved in direct patient treatment.

Methods

We included all patients treated in the trauma room from 2016/01/01 to 2016/12/31 that were documented with the trauma module of the German Emergency Department Medical Record V2015.1. We divided the data into documentation by medical documentation assistant (DA, 07:00 to 17:00), physician in daytime (PD, 07:00 to 17:00), and physician at night (PN, 17:00 to 07:00). Data were analyzed for completeness (primary outcome parameter) as well as diagnostic intervals.

Results

There was a significant increase in complete recorded data for DA (74.5%; IQR 14.5%) compared to PD (26.9%; IQR 18.7%; p < 0.001) and PN (30.8%; IQR 18.9; p < 0.001). The time to whole-body computed tomography (WBCT) significantly decreased for DA (19 min; IQR 8.3) compared to PD (24 min; IQR 12.8; p = 0.007) or PN (24.5 min; IQR 10.0; p = 0.001).

Conclusion

In presence of a qualified medical documentation assistant, data completeness and time to WBCT improved significantly. Therefore, utilizing a professional DA in the trauma room appears beneficial for data quality and time management.
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Metadata
Title
The impact of a qualified medical documentation assistant on trauma room management
Authors
Benjamin Lucas
Sophie-Cecil Mathieu
Gerald Pliske
Wiebke Schirrmeister
Martin Kulla
Felix Walcher
Publication date
01-02-2022
Publisher
Springer Berlin Heidelberg
Published in
European Journal of Trauma and Emergency Surgery / Issue 1/2022
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-020-01513-y

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