District Hospital Trauma Mental Health Screening Clinical Documentation Template Field Order and Post-Traumatic Stress Disorder Symptom Underreporting in Zambian Referral Facilities: A Cluster-Randomised Evaluation of Form Architecture

Post-traumatic stress disorder (PTSD) is frequently under-detected in African trauma populations, and the architecture of clinical documentation forms has been proposed as one contributor to this detection gap. The study was designed as a two-arm parallel cluster-randomised trial across district hospital trauma units, with units allocated to either a symptom-first form (PTSD items placed before demographic and injury fields) or a symptom-last form (PTSD items placed after all administrative fields). The primary outcome was the documented PTSD symptom count per eligible trauma patient, extracted from completed forms over a twelve-month period. Secondary outcomes were the proportion of forms with any PTSD symptom documented and the proportion meeting a documented symptom threshold consistent with probable PTSD. Analysis was by intention-to-treat at the cluster level, with mixed-effects models accounting for clustering by facility. The trial was designed to detect a standardised difference of 0.35 in documented symptom counts with 80% power at a two-sided alpha of 0.05. The results indicate that form architecture is a modifiable determinant of PTSD symptom documentation and that symptom-first ordering is associated with higher documented symptom counts. The findings have implications for the design of trauma mental health screening instruments in low-resource referral settings and for the interpretation of PTSD prevalence estimates derived from routine documentation.