Analysis on the completeness of case records of patients with penetrating ocular trauma following a multimodal intervention.

Purpose: To describe the process development of a multimodal intervention and the pre- and postintervention results on the completeness of case records of patients with penetrating ocular trauma in a high-volume tertiary eye care hospital in south India.

Methods: A multimodal intervention including an objective-validated case sheet template, an education program, a physical template case record reminder, a continuous near-real time audit process, and a feedback system was developed. Analysis on the completeness of the case records of patients with ocular trauma from October 2020 to December 2020 (preintervention) and from January 2021 to March 2021 (postintervention) was performed. These case records and the personnel involved in the documentation, were given scores based on the scores assigned to the subsections of the validated template case sheet. The mean total score of the case records and of the personnel involved were analyzed.

Results: One hundred and eleven case records of patients with ocular trauma who underwent primary wound repair were included in the study. Of these 111 case records, 46 belonged to preintervention group and 65 belonged to postintervention group. The mean total score for preintervention group during the study period was 57.93 ± 24 out of 100 and for postintervention group was 99.07 ± 4.49 out of 100. The temporal trend of postintervention group showed a consistent improvement every month (97.14, 100,100) during the 3-month study period. Postintervention improvement was noted in all the sections of case records completed by both fellows and consultants.

Conclusion: A sustained improvement in ocular trauma case record documentation among all levels of medical professionals was noted following the five-component multimodal intervention.