[Multiple trauma management: reliable documentation of the 1st phase supplying a standardized, machine-readable encounter sheet for the emergency rescue team]

Abstract

Adjust preclinical treatment is an inevitable compound of polytrauma-management. Instantaneously applied expert therapy of the traumatic shock and acutely performed diagnosis of the pattern and dignity of injuries often are crucial for the patients' outcome. Precise documentation of the first phase of treatment thus gains importance for clinical investigations to come and for questions put scientifically. Applying data processing with data input through an optical mark reader a standardized encounter sheet, that proved to be usable as a checklist, has been developed in our hospital for the emergency-rescue-team. Being simple to use and handy to fill out it serves as a clinical record as well as a means for direct data input to a personal computer. The encounter sheet is presented in this paper together with first results of the application in daily routine.