• J Hamill, R Paice, and I Civil.
• Trauma Services, Auckland Hospital. hamill@clear.net.nz
• N. Z. Med. J. 2000 Apr 28;113(1108):146-8.

AimsTo examine the impact of a standardised trauma form for documentation in cases of major trauma, a prospective study was undertaken.MethodsRecords written by medical staff pertaining to the assessment and treatment of major trauma patients in the resuscitation room were scored against a panel of parameters derived from advanced trauma life support guidelines. Demographics, aetiology, trauma scores and outcome data were obtained from a trauma registry. Attitudes of medical staff involved in major trauma to the trauma form were assessed using a questionnaire.ResultsThe trauma form was used in 53 of 69 (76.8%) consecutive cases of major trauma seen over a three month period. No significant differences existed in demographics, aetiology, trauma scores or outcome between form and formless groups. In the form group, a median of 44 of 51 (86.3%) relevant information parameters were documented versus 32 of 51 (62.7%) in the formless group, p < 0.0001. A positive approach to the trauma form was indicated by the questionnaire results.ConclusionThe use of a standardised form improves documentation in major trauma.

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