"Who's scribing?": documenting patient encounter during trauma resuscitation

With healthcare moving towards electronic health records, it is important to understand existing work practices to design effective systems. We conducted an observational study in a Level I trauma center to examine the documentation process and the role of the nurse recorder in trauma resuscitation. We identified several difficulties with current recording practices, including the late arrival of the nurse recorder, parallel activities of the trauma team, and multitasking by the recorder. Our observations showed that the recorder’s role extends beyond archival responsibilities. The recorder, with the help of a paper record, manages the resuscitation process, rather than passively documenting it. Our findings highlighted the complexity of the recorder’s role and the need to consider documentation in the broader context of trauma teamwork. We proposed a set of design challenges that emphasize important aspects of trauma care to be considered when designing technologies to support th...

• Type: Journal
• Year: 2010
• Where: CHI
• Authors: Aleksandra Sarcevic
• Keywords: CHI 2010, Human Computer Interaction, Nurse Recorder, Recorder’s Role, Trauma Resuscitation