Aims A large multi hospital audit across Greater Glasgow and Clyde of compliance with the protocol ‘Recognition and management of maltreatment in infants’ had demonstrated that history taking, examination and note keeping was often inadequate. A proforma was introduced to be used in all children under the age of one year presenting with an injury. A second audit was carried out to see what the impact of this proforma was.
Methods A protocol has been implemented in Greater Glasgow and Clyde to be followed in all children under the age of one presenting to emergency departments where there is concern about welfare and protection. A multi hospital audit was carried out to evaluate the compliance with this protocol. In the first audit cycle 272 sets of emergency department records were audited, of children that had presented to emergency departments in August, September and October of 2012, findings were noted on detail of history taking, documented examination and note keeping. Areas for improvement were highlighted following the first round of the audit and a new under 1’s injury proforma was introduced by emergency medicine. This proforma is used to assess all children under the age of one year who attend an emergency department with an injury. A second audit cycle was completed in August, September and October of 2014 looking at 375 sets of emergency department notes.
Conclusions Introduction of a proforma improved history taking, examination and notekeeping in children under the age of one year of age presenting to emergency departments in Greater Glasgow and Clyde.
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