Aim: To determine if the introduction of preformatted patient record charts improved documentation by doctors in a rural emergency department.
Methods: All medical records of patients who were discharged from the emergency department were collected and analysed for a period of two weeks (control). The preformatted patient charts were then introduced for a further two weeks, and analysed for the presence or absence of key content items
Results: After exclusions, 137 control charts and 96 preformatted charts were collected and analysed. It was found that, overall, there was a significant improvement in the number of the key items documented (p<0.005). There was a trend towards improvement in four parameters, but for three other key content items, there was a nonsignificant decline in documentation standards.
Conclusion: A structured proforma does improve documentation. However, the improvement is small and further studies are required before use of preformatted patient records for the undifferentiated emergency department patients can be recommended.