492 Enhancing Trauma Documentation Accuracy: A Closed-Loop Analysis at a Major Trauma Centre in North Scotland

Aim Aims to evaluate the documentation accuracy of Mechanism of Injury (MOI) and Neurovascular Status (NVS) for trauma patients within a Trauma and Orthopaedic (T&O) ward at a Major Trauma Centre in North of Scotland. Method Review of admission and ward notes spanning two weeks included trauma cases with varying mechanisms of injury, excluding elective cases. Results Results from two cycles revealed a total of 67 patients. Noteworthy improvements were observed in MOI documentation rates, rising from 85.3% to 87.9% for Foundation Year (FY) doctors and 76.5% to 97% for Registrars. Equally significant improvement in NVS examination documentation were identified, increasing from 23.5% to 42.4% for FY doctors and 20.6% to 42.4% for Registrars. However, the documentation rate of "NVI" remained relatively static at 50% to 49%. Conclusions While overall documentation of MOI and NVS improved between foundation doctors and registrars, the study underscores suboptimal "NVI" documentation and the inadequacy of relying solely on acronyms. The proposed plan involves continued formal teaching on NVS examination, incorporating it into the FY teaching package, and a scheduled third cycle in 2024 for ongoing assessment and improvement.