Objective Patients with injuries to the midface frequently sustain ophthalmic injuries and fractures to the facial bones. Despite this, basic ophthalmic examination and assessment of important clinical signs are often missing from the records of patients attending the emergency department (ED). We implemented a structured record keeping tool to improve documentation for patients presenting to the ED with midface injuries.

Methods At our institution, a structured record keeping tool was introduced to document important clinical features of maxillofacial injuries. This assessment tool included 17 key clinical diagnostic signs and symptoms including a six-part basic ophthalmic examination. We audited 369 patients attending the ED with suspected midface bony injuries using this tool.

Results A statistically significant improvement in the documentation of all six ophthalmic parameters was seen. The documentation rate of visual acuity increased by 41.1% (SE 2.8; p<0.001); diplopia by 45% (2.9; p<0.001); double vision by 51% (2.9; p<0.001); lateral subconjunctival haemorrhage with no posterior limit by 83% (2.6; p<0.001) and enopthalmous by 86% (2.4; p<0.001). Documenting whether pupils were equal and react to light increased by 14% (1.4; p<0.001). In addition, 10 out of 11 non-ophthalmic parameters showed significant improvement. The mean global record keeping score increased from 45.3% (95% CI 42.7% to 47.7%) to 99.1% (95% CI 98.2% to 100%; p<0.001).

Conclusions This work demonstrates that a structured record keeping tool is a simple and effective method of significantly improving clinical documentation for patients with facial injuries presenting to the ED.