DOCUMENTATION

Accurate, and complete documentation promotes patient safety, and facilitates patient transfer, handover, and continuity of care. Documentation is required at all levels of care and can be challenging. In the ARSC environment, documentation is essential not just as part of a clinical standard but secondary to the need to further define, refine, and understand the limitations of this battlefield capability. The relatively low volume of causalities these teams have managed combined with the paucity of documentation received for Performance Improvement analysis makes understand the true capability and capacity of ARSC teams a challenge. Additionally, appropriate and reliable analysis requires accurate and complete data, which will then, allow more appropriate medical planning. In some cases, documentation and transmission is challenging due to a lack of communication equipment that enables reliable communications with higher levels of medical care. The ARSC environment is resource and personnel limited, and time must be committed to complete documentation on all patients. Experience has shown that in the setting of a MASCAL (when taking time to document seems the most challenging), proper documentation aids with communication, decreases redundant evaluations, avoids errors, and ensures complete care. Consider language barriers with documentation. In unconventional warfare and depending on the unit the ARSC team is supporting, using patient identifiers may not be permitted. If caring for host national casualties, using non U.S. forms in their native language may be beneficial medically and practically.

The JTS MASCAL/Austere Trauma Resuscitation Record and an operative note and anesthesia record for surgical patients is the minimum required documentation for all patients. Minimum documentation includes mechanism of injury, injuries identified, signs and symptoms, and treatments, vital signs, neurologic status, medications, and interventions provided. Follow the Combatant Command or regional standard naming convention for trauma pseudo names and maintain one consistent name for each patient during transfers. This improves continuity of care, patient tracking, blood resupply, and outcome analysis. In the operational setting include ethnicity, unit affiliation, and geographic location of injury as able. Use the JTS Burn Resuscitation Flow Sheet for major burns and prolonged field care flow sheet for prolonged care. When evacuating to higher level of care, records should be transferred with the patient. A photograph or copy of the record should be kept by the surgical team in the event the record is lost. When documentation cannot be completed prior to patient evacuation, complete the documentation immediately after evacuation and send it electronically to the next level of care as soon as able. Submit patient records to the DoD Trauma Registry (DoDTR) via dha.jbsa.healthcare-ops.list.jts-trauma-registry@health.mil or to the closest Role 3 or 4 medical treatment facility patient administration as soon as able. Keep a log of all trauma patients and submit to the DoDTR.