Quality improvement in documentation for @entity1 with suspected XXXX : use of a structured record keeping tool.

@entity1 @entity11253 @entity174 @entity548 @entity341 @entity8494 @entity892 @entity130
OBJECTIVE: @entity1 with injuries to the midface frequently sustain ophthalmic injuries and @entity174 to the facial bones. Despite this, basic ophthalmic examination and assessment of important clinical signs are often missing from the records of @entity1 attending the @entity341 ( @entity341 ). We implemented a structured record keeping tool to improve documentation for @entity1 presenting to the @entity341 with @entity130 . METHODS: At our institution, a structured record keeping tool was introduced to document important clinical features of @entity11253 . This assessment tool included 17 key clinical diagnostic signs and symptoms including a six-part basic ophthalmic examination. We audited 369 @entity1 attending the @entity341 with suspected midface bony injuries using this tool. RESULTS: A statistically significant improvement in the documentation of all six ophthalmic parameters was seen. The documentation rate of visual acuity increased by 41.1% (SE 2.8; p<0.001); @entity892 by 45% (2.9; p<0.001); double vision by 51% (2.9; p<0.001); lateral subconjunctival @entity548 with no posterior limit by 83% (2.6; p<0.001) and enopthalmous by 86% (2.4; p<0.001). Documenting whether pupils were equal and react to light increased by 14% (1.4; p<0.001). In addition, 10 out of 11 non-ophthalmic parameters showed significant improvement. The mean global record keeping score increased from 45.3% (95% CI 42.7% to 47.7%) to 99.1% (95% CI 98.2% to 100%; p<0.001). CONCLUSIONS: This work demonstrates that a structured record keeping tool is a simple and effective method of significantly improving clinical documentation for @entity1 with @entity8494 presenting to the @entity341 .
