The authors begin by emphasising the importance of complete medical records in maxillo-facial trauma by pointing to the fact that the records not only provide the necessary clinical information but also provide legal protection of both the patient and the health care provider. The authors have developed a complete and comprehensive proforma for maxillo-facial trauma that is also designed to be easy for junior doctors to complete. The proforma, accompanied by figures, has four component parts: demographic data, presentation and findings, treatment and outcomes. This proforma was compared to handwritten trauma records in an audit. While only 25% of the handwritten notes were considered to be complete in two or more categories with important omissions, the new proforma showed a 92% satisfactory completion rate. The reported time taken to complete the form was around eight minutes. Encouraged by its successful introduction into the department routine the authors created a dedicated software package on the same format which has been incorporated into their computers in clinics, offices and operating theatres in their department. Apart from the clinical information, the areas where information is made available in the proforma are: percentage of trauma patients who present outside office hours, basic demographic data, type of injury and mechanism, audit of clinical care and documentation, seasonal variations, changing trends in maxillo-facial trauma, delays to the theatre, volume of routine and out-of-hours work, complication rates, annual throughput of trauma, departmental fiscal accountability and areas where training needs to be improved. The proforma is available at the first author’s email address, JASherman@doctors.rg.uk.
A comprehensive proforma for maxillo-facial trauma
Reviewed by Sampath Chandra Prasad
Proforma for maxillofacial trauma.
