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A trauma flow sheet can streamline documentation and improve care, says Carol Buschur, RN, CEN, clinical coordinator for the ED at the University Hospital in Cincinnati.
"We created this flow sheet because we wanted a more consistent assessment and documentation form for our critical cases," she says. "We looked at many different forms and came up with a systematic approach."
Here are some components of an effective trauma flow sheet:
• Less time spent writing narratives. A standardized format for different categories and the preprinted findings help the nurse document a complete, accurate, and quick assessment.
"We took out a lot of the narrative pieces by using checks in boxes, prompts, and circles on a body graph. The nurse spends much less time writing it out, and you get a head-to-toe picture of the patient."
• Increased accuracy. "We needed more accurate assessment and documentation," says Buschur. "We also had to consider the time element involved in adequate documentation of our practice. In our ED, we have 76,000 visits per year with a very tight staffing pattern, so we needed a user friendly but effective documentation tool."
To improve accuracy, the form features preprinted assessment findings with boxes in front of each finding. "The boxes can simply be checked for positive findings," Buschur explains. "Other essential assessment pieces that require more than a check are identified by a word prompt and a line for brief notation."
• Improved assessment. "When we have a critical care patient, we tend to focus on just the injury. Our goal with this form is to do a complete general assessment, looking at the whole patient," says Buschur. "We use functional categories as a systematic approach to assessment; first the ABCs, then the other assessment areas. Once we have the most life-threatening issues under control, we can complete our assessment of the entire patient/family."
The 10 functional categories used are respiratory, cardiovascular, injury/mobility, comfort/pain, sensory/perceptual, nutrition, elimination, skin/safety, coping, roles/relationships, and health perception/promotion.
"With the incredible pace we work at, a preprinted systematic format helps us assure that our assessments are complete," says Buschur.
• Decreased length of stay. The form decreases a patient’s length of stay, notes Embeth Bauer, RN, also an ED nurse at The University Hospital in Cincinnati.
"The hospital stay for these critical patients can actually be decreased if we follow the assessment format on the ED flow sheet. From the time they come into the ED, we can begin planning discharge from the hospital, based on their individual needs," she explains.
The form helps nurses to identify patient and family needs. "Many families cannot stay through the ED process and the admission process. Often, the ED RN is the first to discover pertinent concerns from the patient or family before they are admitted into the hospital. We get ballpark ideas of what the family will need to discharge a patient based on the findings," says Bauer.
Prompting the nurse to assess and document this information can help expedite the resolution of psycho-social issues that need to be addressed before the day of discharge. "Family education and home situations need to be identified early on and communicated to social workers. That way, once the patient is admitted and treated, the process of discharge from the hospital can be smoother."
For example, a trauma patient may be the primary financial income for a family with three small children, notes Bauer.
"There may be a patient who comes in with angina for a ruleout MI, and they may be responsible for taking care of an elderly relative," she explains. "They may live on the third floor, or may need support to take care of them when they go home. The form allows us to immediately take these needs into consideration instead of on the day of discharge."
• Better communication with floor nurses. "As we increase documentation of our assessment, it is easier for other nurses to know how the patient presented and what we have done," says Buschur. "This form encourages a thorough and consistent initial assessment as a baseline for subsequent assessments, whether this takes place in the ED or on another unit."
A copy of the form goes with the patient to whichever unit they are taken, Buscher explains. "The form communicates our practice, which should be based on data and facts vs. assumptions and guesswork."
• More involvement with other staff. "The form is no longer just a nursing record. We made it a patient care record so the ownership isn’t just nursing, it’s multidisciplinary," Buschur explains. "There are areas on the form where physicians and other disciplines can document. If respiratory therapy comes down, they can write on this form to document their care and interaction with the patient, so it’s not just a nursing process."
The form is designed to be user friendly for everyone, stresses Bauer. "The most frequent physician orders are written in, and have checkboxes for ordering. Other areas of the form include procedures, lab results, and medications."
• More consistency. A copy of the form always goes with the patient. "A patient in the ED may stay longer than we anticipate, so many nurses can be caring for the same patient," Buschur explains.
• Easier to use. At Lahey Hitchcock Medical Center in Burlington, MA, the ED staff noticed the trauma flow sheet was difficult to use because the recorder had to jump from one area of the form to another to record information.
"Documentation was very frustrating, because the members of the trauma team would call out appropriate information, but the recorder would be unable to keep up," says Nicki Gilboy, RN, MS, CEN, former nurse educator at the Lahey Hitchcock ED and currently nurse educator in the ED at Brigham and Women’s Hospital in Boston.
A new form was created based on a logical flow of events. (See Emergency Trauma Flow Sheet, inserted in this issue.) "The documentation now follows logically, from prehospital to admission to discharge," adds Gilboy.
• Increased focus on patient’s psychosocial needs. At Lahey’s ED, the trauma flow sheet specifically addresses the patient’s psychosocial needs. "Our nursing staff felt strongly that specific information addressing the patient’s psychosocial needs should be included, because that reflects one of nursing’s focuses," says Gilboy.
For more information on creating a trauma flow sheet, contact:
• Embeth Bauer, RN, The University Hospital, 234 Goodman St., Cincinnati, OH 45267. Telephone: (513) 558-5281. Fax: (513) 584-2637.
• Carol Buschur, RN, CEN, The University Hospital, 234 Goodman Street, Cincinnati, OH 45267. Telephone: (513) 584-3379. Fax: (513) 584-2637.
• Nicki Gilboy, RN, MS, CEN, Emergency Department, Brigham and Women’s Hospital, Boston. Telephone: (617) 732-4824. Fax: (617) 278-6977. E-mail: email@example.com.