Jefferies JG, Brown CD, Shields D (2019) A Dedicated Orthopaedic Trauma Admission Document Significantly Improves Recording of Patient Information. Int Arch Orthop Surg 2:011.


© 2019 Jefferies JG, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

ORIGINAL ARTICLE | OPEN ACCESS DOI: 10.23937/2643-4016/1710011

A Dedicated Orthopaedic Trauma Admission Document Significantly Improves Recording of Patient Information

Jefferies JG1*, Brown CD1 and Shields D2

1Department of Trauma and Orthopaedics, Glasgow Royal infirmary, Glasgow, 84 Castle street, G4 0ET, UK

2The University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK



Meticulous documentation in clinical records has been shown to improve patient care and clinician performance. Conversely, poor documentation is associated with an increased risk of adverse events. The Royal College of Surgeons (RCS) issues guidance on the contents of surgical admissions documentation.

Audit highlighted frequent omission of key criteria set out by RCS with freehand documentation. We set out to design, implement, and evaluate an orthopaedic admission proforma for our trauma patient population.


Retrospective analysis was performed of freehand clerk-ins against RCS standards. A new orthopaedic admission document was designed, and after an introductory period further retrospective analysis was performed of document clerk-ins with statistical analysis performed.


80 freehand records and 64 Admission documents were analysed. Use of proforma increased documentation in 29 out of 32 criteria set by RCS. This was statistically significant in 22 out of 29 criteria.


Documentation of patient information is significantly improved with use of an admission document. Clerk- in quality is more consistent and comprehensive and is a quick and accessible source of information for all members of the multidisciplinary team. We have designed an effective admission document that is reproducible and an auditable tool that would benefit a range of surgical specialties and unit sizes.