Observational studyBMJ open quality2023
Observational analysis of documentation burden and data duplication in trauma patient pathways at a major trauma centre.
Observational study in BMJ open quality, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
3 citing papers in PubMed, 1 synthesis or guideline pooled it, 2 citations in OpenAlex.
- Measuring Documentation Burden in Healthcare.Journal of general internal medicine · 2024Pooled it
- Evaluation of Socio-Technical Mechanisms Shaping AI Scribe Documentation Failures: A Netnographic Study.Journal of evaluation in clinical practice · 2026Article
- Defining Documentation Burden (DocBurden) and Excessive DocBurden for All Health Professionals: A Scoping Review.Applied clinical informatics · 2024Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors at 3 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesTrauma patients require extensive documentation across paper and electronic modalities. The objectives of this study were (1) to assess the documentation burden for trauma patients by contrasting entries against predetermined key information elements, dubbed 'data entry points' (DEPs) of a thorough trauma clerking, and by evaluating completeness of entries; and (2) to assess documentation for repetition using a Likert scale and through identification of copied data elements.
methodsA 1-month retrospective observational pilot study analysing documentation within the first 24 hours of a patient's presentation to a major trauma centre. Documentation was analysed across three platforms: paper notes, electronic health record (EHR) and patient organisation system (POS) entries. Entries were assessed against predetermined DEPs, for completeness, for directly copied elements and for uniqueness (using a Likert scale).
results30 patients were identified. The mean completeness of a clerking on paper, EHR and POS was 79%, 70% and 62%, respectively. Mean completeness decreased temporally down to 41% by the second ward round. The mean proportion of documented DEPs on paper, EHR and POS entries was 47%, 49% and 35%, respectively. 77% of POS entries contained copied elements, with a low level of uniqueness of 1.3/5. DISCUSSION: Our results show evidence of high documentation burden with unnecessary repetition of data entry in the management of trauma patients.
conclusionThis pilot study of trauma patient documentation demonstrates multiple inefficiencies and a marked administrative burden, further compounded by the need to document across multiple platforms, which may lead to eventual patient safety concerns.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.