Introduction: Inadequate documentation in the acute trauma setting potentially compromises patient care, leads to lost revenue and legal liability. We therefore developed a real time database emulating an electrical medical record to obviate those problems.
Methods: Using a Windows based relational database, an application was developed to track all resuscitation at a busy adult and pediatric level I Trauma Center (TC). Injury description, admit/discharge times, attending/housestaff/nurse, procedures, disposition and complication were recorded. Nurses entered all data upon completion of the resuscitation. Data accuracy was confined with internal algorithms, routine cross-referencing with written logs and periodic attending review. Automatic procedure notes with CPT-codes were provided to billing, medical records & physicians. CQI data was regularly reviewed.
Results: Over a six month period, there were 1,329 resuscitation (1,184 adults & 145 peds). The majority of records were entered within 12 hours of resuscitation; mean entry time was 11.7 min/record. There were 754 procedures (intubation, cricothyroidotomy, needle & tube thoracostomy, DPL, vascular access, pericardiocentesis, and thoracotomy) performed generating patient charges of $271,312. System expenses included $3,000 for capital and $5,705 for labor (TC Nurses: $4,405 + Data Coordinator: $1,300). Using our established reimbursement average of 52%, this yielded a $132,377 net return for accurately and completely documented records. 374 quality concerns were identified, categorized as: Delay-145, radiology-66, Pre-Hospital-51, Triage-40, TC-36, Procedural-19 and Physician-17.
Discussion: This application provided consistent, automated documentation for TC procedures and CQI. With minimal fiscal investments, this tool was cost effective and affords additional intangible benefits of legibility, immediacy, and accountability.