1. RUNNING HEAD: IMPROVING TRAUMA DOCUMENTATION
Improving Trauma Documentation: Simulations and Shadow Charting
Catherine Fitt
Resurrection University

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Improving Trauma Documentation: Simulations and Shadow Charting
Ann and Robert H. Lurie Children’s Hospital of Chicago serves the children of the
Chicagoland area in a variety of ways. The Lurie Children’s Emergency Department (ED) and
Level 1 Pediatric Trauma Center sees approximately 800 trauma victims seen each year. One of
the most challenging trauma roles for these patients is the role of Nurse Documenter. After
conducting an informal survey with ED staff, it was discovered that the role of Nurse
Documenter was considered an extremely challenging role in the trauma room. As the Nurse
Documenter, they are to enter all information pertaining to the events of that trauma patient into
EPIC records in a timely manner. In the Lurie Children’s ED, it has been found that trauma
patients often have incomplete patient records in important data categories such as: social
screenings, vital signs, primary assessments, and trauma scores. “…there is an association
between child deaths following emergency department (ED) attendance and poor record keeping
and information sharing” (Forge, 2014, p.34) Complete electronic medical records (EMRs) are
crucial in order to accurately communicate with other healthcare personnel the events prior to
arrival, events in the trauma room, and the plan of care.
This intervention involves a change in the approach to training nurses to be the Nurse
Documenter. The ED nursing staff is encouraged, but not required, to undergo training prior to
taking on this role. Through formal and informal surveys, the nursing staff in the ED expressed
the desire to have further practice and education prior to taking on the role as the Nurse
Documenter in real traumas. In order to feel confident in this role, two educational interventions
will be implemented in the ED. Through simulations and shadow charting, these interventions
will benefit the unit by preparing nurses to be the Nurse Documenter in the trauma room;
thereby, improving the quality of trauma documentation over time.

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Literature Review: Topic/Issue
Wurster, Groner, Hoffman (2015) investigated the issue of incomplete trauma
documentation and devised a strategy to address this problem in their ED. After the transition
from paper to EMRs, there have been very few trauma centers that have effectively implemented
the use of EMRs during trauma resuscitations. Starting in December of 2008, this team of
researchers decided to implement a program to improve the confidence of Nurse Documenters
during traumas through the use of education and practice documenting. The improvement plan
was had two main educational components: simulations and shadowing charting.
O’Connor, Raposo, Heller-Wescott (2014) conducted a study on improving EMR
documentation in trauma resuscitations. They found that approximately 79% of their ED’s
trauma charts were incomplete and missing valuable patient information. It was also discovered
that those patients with lower injury severity scores were more often noncompliant with chart
completeness. The areas of documentation that were most often missed were “intake and output
measurement, vital signs, and a complete roll call of trauma alert responders” (p. 239). It is
important to note that this emergency department utilized paper trauma documentation due to
then-current financial constraints.
Literature Review: Solution/Intervention
Wurster, Groner, Hoffman (2015) utilized trauma simulations for nurses to practice
documenting trauma EMRs and to help identify areas for improvement within the EPIC system.
These simulations provided nurses with time to practice maneuvering through the complicated
trauma EPIC EMRs and gain confidence before moving on to shadow charting. Shadow charting
was another opportunity for nurses to practice documenting, but instead took place during real-
time trauma scenarios. The nurse who was practicing documenting trauma EMRs would chart

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the real-time trauma in EPICPlayground alongside the designated Nurse Documenter for the
trauma. Once the patient was stabilized, the two nurses would compare the charts and identify
missing information and areas of improvement for the nurse in training. In conjunction with the
simulations and shadow charting, an IT analyst who was also a seasoned ED nurse, created the
training checklist to ensure nurses had completed an adequate amount of trauma EMR education.
It was composed of a two-hour overview of trauma EMRs, two paper chart practice scenarios,
one EPICPlayground practice scenario, one shadow charting experience, and completing a
review of the EMR documentation tablet. This article explained that they would perform an
analysis of the results of this implementation at a later date. Although an analysis of the
effectiveness of this program is not available, other studies from this journal have shown that
similar education methods were successful in improving the quality of trauma documentation.
As the primary implementation in O’Connor, Raposo, Heller-Wescott (2014), they also
implemented education on trauma documentation through in-service classes, staff
brainstorming/discussion sessions, documentation quizzes, charting practice scenarios, and peer
reviewing all trauma charts. In order to analyze the effectiveness of these educational
interventions, the research team assembled a group of emergency department staff to review the
EMRs for completeness and overall quality. After initiating these educational interventions, they
found a significant increase in compliance with complete documentation. In September of 2011,
the percentage of EMRs with deficiencies was at 34%. By December of 2011, the percentage of
deficient EMRs dropped to 10%. As a result, the researchers concluded that this variety of
educational interventions drastically improved the quality and completeness of their trauma
EMRs by thoroughly preparing their nurses in the role of Nurse Documenter. In order to increase

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the strength of their conclusions, these same educational interventions would need to be applied
in a larger number of emergency departments.
Implementation
The proposed strategy to improve the quality of trauma documentation at Ann & Robert
H. Lurie Children’s Hospital of Chicago involves two educational interventions. In collaboration
with the Trauma Coordinator, it was decided that trauma simulations and shadow charting would
be utilized to prepare the ED nursing staff. The ED nursing staff vocalized the desire to practice
the role of Nurse Documenter in order to increase their confidence and familiarity with the EPIC
trauma EMRs. The first educational step will be trauma simulations based on previous patients
that fell into the “Trauma A” category. These simulations will allow nurses time to practice
maneuvering the EPIC trauma charts in a low-stress environment. In these simulations, ED staff
members will be reading from a script that mimics the conversations heard amongst the trauma
team members during a “Trauma A” situation. While the script is being read, the nurse will
practice maneuvering through the EPIC play trauma charts and document accordingly. Once the
simulation is complete, there will be a peer review process by comparing the nurse’s
documentation to the “near perfect” example that was created in reference to that specific
trauma.
After the nurse has gained confidence in their abilities in the simulation environment,
they will move onto practicing through shadow charting. The nurse will chart a real-time trauma
in EPIC play alongside the designated Nurse Documenter who is charting in EPIC. Once the
trauma patient has been stabilized, they will conduct another peer review process to compare the
EPIC play documentation to the EPIC documentation. Not only will this provide a real-time
opportunity for a nurse to practice documenting in the stressful trauma environment, but it will

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also give the designated Nurse Documenter another set of ears in the trauma room. This
additional person could help that Nurse Documenter fill in any missing information once the
patient has been stabilized.
These educational interventions will help improve the confidence in the Nurse
Documenter prior to carrying out the role during a real trauma. After increasing the familiarity
with documenting traumas in EPIC among the nursing staff, a decrease in the amount of
incomplete trauma EMRs may be seen. These interventions are also designed to gradually
increase the stress of the environment when moving from simulation to shadow charting. This
change in stress will aid the nurse in focusing on growing their confidence in accurate
documentation rather than worry about the stress of the trauma environment. Once this
confidence is gained, the nurse can exercise their new competency as the Nurse Documenter
during live traumas. The Ann & Robert H. Lurie Children’s Hospital ED staff has been pushing
for all nurses to undergo training prior to undertaking the role as Nurse Documenter. The
implementations of simulated traumas, shadow charting, and peer reviews will aid in this push
for Nurse Documenter training. In the future, the trauma staff can utilize these simulation
templates to develop more complicated trauma simulations. These implementations and
developments will further increase the efficiency of the Nurse Documenters in the trauma room.

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References
Forge, J. (2014). Role of effective documentation in emergency departments. Emergency Nurse,
22(3), 34-37. doi:10.7748/en.22.3.34.e1304
O'Connor, T., Raposo, A., & Heller-Wescott, T. (2014). Improving trauma documentation in the
emergency department. Journal of Trauma Nursing, 21(5), 238-243.
doi:10.1097/JTN.0000000000000071
Wurster, L., Groner, J., & Hoffman, J. (2015). Electronic documentation of trauma resuscitations
at a level 1 pediatric trauma center. Journal of Trauma Nursing, 19(2), 76-79.
doi:10.1097/JTN.0b013e31825629ab