# Unlocking the Potential of Underutilized Technology: A New Paradigm for Resident Doctor Efficiency

## TL;DR

This study shows that using autotext templates improves how accurately doctors document patient assessments in trauma and orthopaedic surgery.

## Contribution

The study introduces an autotext template intervention that significantly improves adherence to clinical documentation standards in trauma care.

## Key findings

- Pre-intervention, only 8.5% of documents included detailed motor function assessments.
- Post-intervention, 91.23% of documents listed nerves and 96.49% used the MRC grading scale for motor function.
- The intervention showed statistically significant improvements (P < 0.001) in documentation quality.

## Abstract

Background

The precision of clinical documentation in trauma and orthopaedic surgery is pivotal, given its profound implications on patient care and medicolegal risks. This study assessed the impact of an autotext template intervention on the adherence of clinical documentation to the neurovascular assessment standards set by the National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association Standards for Trauma (BOAST).

Methods

Conducted at a single hospital, this observational study comprised two phases: a retrospective analysis of clinical documentation for 56 fracture patients (n=56) followed by the implementation of an autotext template and subsequent analysis of a new cohort of 57 patients (n=57). The intervention aimed to enhance documentation quality in line with NICE and BOAST guidelines.

Results

Initial findings revealed a prevalent use of the nonspecific term "NVI" (neurovascularly intact), with only 8.5% (n=5) of pre-intervention documents adhering to detailed motor function assessments and a mere 6.8% (n=4) recording limb colour. Post-intervention analysis showed a significant improvement, with 91.23% (n=52) of documents listing nerves (P < 0.001) and 96.49% (n=55) adhering to motor function documentation using the Medical Research Council (MRC) grading scale (P < 0.001). Despite these advancements, the study acknowledges potential limitations such as the Hawthorne effect and the ongoing challenge of staff rotations.

Conclusion

The autotext template intervention markedly enhanced the adherence to neurovascular assessment documentation standards, as evidenced by the substantial increases in detailed parameter reporting and supported by statistically significant P-values. This advancement highlights the necessity of equipping clinicians with practical tools to uphold high documentation standards amidst challenging clinical conditions. Future investigations should focus on the long-term sustainability of these improvements across varying medical staff cohorts.