Trauma Flow Sheet Performance Improvement Tracking- January 2008
Objective: Performance Improvement audits of the trauma flow sheet will be done on a
weekly basis to ensure accurate and complete written documentation. All
missing documentation will be followed up, completed and signed off within
one week of receiving the chart audit tool. Can be signed off for completion
by the ED Manager, ED Supervisor, ED Educator or the Trauma Program
Manager.
Procedure:
1. Complete trauma flow sheet charting.
2. Copy Trauma Flow sheet chart twice. Place one copy in the ED MD dictation slot
and the other copy goes with the patient for the inpatient chart.
3. The yellow copy of the flow sheet is placed in the Charge leader box for charges
to be completed. The Trauma Registrar is given the yellow copy when charges
are completed.
4. When the registrar data is completed, the trauma flow sheet copy will be sent to
the Trauma Program Manager.
5. Audits will be conducted per the trauma flow sheet audit form weekly. All
monthly stats will be obtained. The copy of the trauma flow sheet and the audit
tool will be returned to the primary nurse. The audit form will be dated when
returned to the primary nurse.
6. The Primary nurse, within one week, will obtain the chart and complete all
missing documentation.
7. When the documentation is completed, the form will be returned to the ED
Manager, ED Supervisor, or Trauma Program Manager to be checked for
completeness. This requires the chart with the original trauma flow sheet and the
audit tool.
8. When checked, the audit form will be signed and returned to Trauma Program
Manager.
9. The Trauma Program Manager will trend all charts for accuracy and
completeness. Any discrepancies or trends will be shared with the ED Manager.
10. Finally, the original chart will be sent to the chart if the patient is still in-house or
to Health Information if the patient has been discharged.
Attachment: The trauma flow sheet PI tracking/audit tool
TRAUMA FLOW SHEET QA
Nurse Recorder________________________________________
Charting Complete
YES
DOCUMENTATION AUDIT
NO
YES
NO
COMMENTS
Times- Response includes name of MD,
time paged and time responded
Trauma Blue / Trauma Consult Activation
Time
Trauma surgeon Response
Neurosurgeon Response
Orthopedic surgeon Response
Assessment:
Primary Assessment: ABCDE
Secondary Assessment
Vital signs, GCS & RTS
Temp, P, RR, B/P, SaO2
ETCO2 if intubated
GCS X 2
Revised Trauma Score X 2
Meds, Fluids, I&O
Tetanus Status (page one)
Given?
Input
Totaled?
Output
Totaled?
Category of Trauma Response:
TB, TC, TA
Patient Disposition from ED
Date, Time, Place
Pain Scale
Initial Pain Assessment
Subsequent Pain Assessment
Date given to the Primary Nurse: ________________
Chart documentation completed Date:_______________
Verified chart completion- Signature of ED Leadership staff or TPM __________________
Date_______________