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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.
摘要：
背景技术创伤和骨科手术中临床文件的准确性至关重要,鉴于其对患者护理和法医学风险的深远影响。这项研究评估了自动文本模板干预对临床文档遵守国家健康与护理卓越研究所（NICE）和英国骨科协会创伤标准（BOAST）设定的神经血管评估标准的影响。方法在一家医院进行，这项观察性研究包括两个阶段:对56例骨折患者(n=56)的临床文件进行回顾性分析,随后实施自动文本模板,随后对57例患者(n=57)的新队列进行分析.干预措施旨在根据NICE和BOAST指南提高文档质量。结果初步发现揭示了非特异性术语“NVI”(神经血管完整)的普遍使用，只有8.5％（n=5）的干预前文件坚持详细的运动功能评估，只有6.8％（n=4）记录肢体颜色。干预后分析显示有显著改善，91.23%(n=52)的文件列出神经(P<0.001)和96.49%(n=55)的文件坚持使用医学研究理事会(MRC)分级量表(P<0.001)的运动功能文件。尽管取得了这些进步,该研究承认潜在的局限性，如霍桑效应和员工轮换的持续挑战。结论autotext模板干预显着增强了对神经血管评估文件标准的依从性。详细参数报告的大幅增加证明了这一点，并得到了统计学上显著的P值的支持。这一进步凸显了为临床医生配备实用工具以在具有挑战性的临床条件下坚持高文档标准的必要性。未来的调查应侧重于这些改进在不同的医务人员群体的长期可持续性。
