Enhancing Documentation of Upper Limb Specialist Team Meetings at a Tertiary Trauma Centre.

BACKGROUND

Specialist team meetings play a key role in the management of complex trauma and reconstructive cases, but their impact depends on accurate documentation. Inconsistent or informal record-keeping risks duplication, transcription errors, and loss of critical information, with implications for governance and patient safety.

METHODS

A quality improvement project was undertaken in the upper limb specialist team meeting at a tertiary trauma centre. At baseline, outcomes were recorded as PowerPoint slides stored in a shared folder without systematic entry into the electronic patient record (EPR). Interventions included the introduction of a structured documentation template, centralised storage, and a shared worklist integrated into the clinical portal. A re-audit of all meetings between 16 May and 22 November 2024 assessed completeness of documentation, reasons for omissions, and qualitative benefits for patient care.

RESULTS

At baseline, no complex patient outcomes were documented in the EPR. Following the intervention, 44 complex cases were reviewed, of which 39 (89%) had outcomes recorded directly in the EPR through the shared worklist. The five undocumented cases occurred during the junior doctor changeover period, highlighting the importance of robust handover processes. The new system also improved accessibility, facilitated follow-up, and strengthened clinical governance by creating a permanent, retrievable record of decisions.

CONCLUSION

Structured, EPR-integrated documentation substantially improved the completeness and accessibility of specialist team meeting records, supporting safer patient handover and stronger governance. These findings align with international evidence that high-quality electronic records improve care quality and suggest that similar frameworks could be applied across subspecialty services to standardise documentation and enhance patient safety.