TY - JOUR
T1 - Implementing a tertiary survey in the emergency general surgery population
T2 - Imitation is the sincerest form of flattery
AU - Eaton, B.
AU - Bonenclark, L.
AU - O'Meara, L.
AU - Tobin, N.
AU - Bruns, B.
AU - Diaz, J.
N1 - Publisher Copyright:
© 2022 Elsevier Inc.
PY - 2022/7
Y1 - 2022/7
N2 - Objectives: The inherent complexity of the Emergency General Surgery (EGS) patient may preclude precise documentation at admission. To obviate lapses in documentation, an EGS tertiary survey (EGS-TS) was developed to enable early recognition of relevant omissions in documentation and clinical findings. We theorized that the creation of the EGS-TS would promote more thorough clinical documentation. Methods: A prospective observational study was performed utilizing an EGS-TS from February 2019 through May 2019. The EGS-TS included physical exam, medication reconciliation, analysis of documentation for accuracy, and review of diagnostic imaging for incidental findings. Results: There were 139 EGS admissions during the study period and 108 (78%) received an EGS-TS. Of those who received the EGS-TS, incorrect medication reconciliations (72%), incidental findings (12%), undocumented wounds (11%), and undocumented indwelling catheters were identified (6%). Conclusion: Implementation of an EGS-TS triggers a detailed evaluation and reveals opportunities for education, improved adherence to documentation standards, and further research that may guide quality improvement initiatives.
AB - Objectives: The inherent complexity of the Emergency General Surgery (EGS) patient may preclude precise documentation at admission. To obviate lapses in documentation, an EGS tertiary survey (EGS-TS) was developed to enable early recognition of relevant omissions in documentation and clinical findings. We theorized that the creation of the EGS-TS would promote more thorough clinical documentation. Methods: A prospective observational study was performed utilizing an EGS-TS from February 2019 through May 2019. The EGS-TS included physical exam, medication reconciliation, analysis of documentation for accuracy, and review of diagnostic imaging for incidental findings. Results: There were 139 EGS admissions during the study period and 108 (78%) received an EGS-TS. Of those who received the EGS-TS, incorrect medication reconciliations (72%), incidental findings (12%), undocumented wounds (11%), and undocumented indwelling catheters were identified (6%). Conclusion: Implementation of an EGS-TS triggers a detailed evaluation and reveals opportunities for education, improved adherence to documentation standards, and further research that may guide quality improvement initiatives.
KW - Advanced practice provider
KW - Emergency general surgery
KW - Structured patient assessment
KW - Tertiary survey
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U2 - 10.1016/j.amjsurg.2022.02.047
DO - 10.1016/j.amjsurg.2022.02.047
M3 - Article
C2 - 35227490
AN - SCOPUS:85125343671
SN - 0002-9610
VL - 224
SP - 85
EP - 89
JO - American journal of surgery
JF - American journal of surgery
IS - 1
ER -