AB246. SOH25_AB_180. Audit of maxillofacial trauma assessments in the National Trauma Centre and introduction of a maxillofacial trauma proforma

Background: Accurate and complete patient records are essential in maxillofacial trauma. An assessment which omits key information compromises patient care. Thorough assessments provide evidence of the consultation and legal protection for both the patient and clinician.

Methods: A retrospective audit was completed in the Mater Hospital (National Trauma Centre in Ireland). This audit assessed undocumented maxillofacial information in patient paper charts. A custom proforma sheet was then designed alongside two consultants. We aimed to standardise the process of documenting trauma assessments, ensuring a comprehensive assessment and avoid missing information. This trauma assessment can be completed on a single double-sided piece of paper. It prompts a systematic approach to trauma assessments and detailed recording of all necessary details should any medical reports be required by police or a court of law.

Results: Thirty consults carried out by non-consultant hospital doctors (NCHDs) over a six-month period were audited. Overall, the maxillofacial consults which were carried out in the National Trauma Centre were well documented. However, 40% had one or more relevant pieces of information missing. The retrospective audit of paper charts demonstrated a clear need for a proforma.

Conclusions: The development of this proforma will guide NCHDs on how to structure and record trauma assessments and ensure a thorough examination. It will also help consultants while completing medico-legal reports in the future as it will ensure all necessary details for these reports are documented. A further audit cycle will be completed in 6 months’ time to get feedback and assess the use of the proforma.

Keywords: Audit; assessments; maxillofacial; proforma; trauma