This session will provide the participants with the purpose, background, and qualitative improvements gained in leveraging technology to promote real-time documentation. We were able to achieve a simplified way for the interdisciplinary members of a trauma team in the emergency department (ED) to record accurate and real-time arrival and departure times in the trauma narrator thru the use of an RFID reader. Participants of the trauma team simply tap their badge prior to entering the trauma bay and the arrival is instantly reflected in the documentation fields of the trauma narrator.
Our organization is a level-1 trauma center. In order to maintain this accreditation, it is critical that we capture quality, real-time documentation reflecting all care provided to our patients during a trauma incident. Prior to badge scanning for the trauma narrator, the scribe nurse would manually document the arrival of all trauma participants to the best of their recollection. This process was not always accurate and frequently resulted in back charting.
Improvements in documentation compliance were measured by capturing reports of staff that badged in at a specific workstation, as well as a chart review of trauma patients. Auditing this process is important in order to maintain level-1 trauma accreditation status. The charts are reviewed are audited for completion of the staff arrival section of the trauma narrator.
From this session, learners will gain insight into how this implementation could improve critically important narrator documentation, encourage real-time documentation for specialty events (trauma, code, procedure, and stroke), improve staff satisfaction, and save time documenting, which in turn can be redirected to time spent at the bedside.