Abstract

Objective: To assess and improve the documentation of ocular trauma examinations in an ophthalmology emergency department through the implementation of a structured proforma and focused training.
Methodology: This quality improvement project (QIP) was conducted in two 30-day cycles at the Ophthalmology Department of MTI-Khyber Teaching Hospital, Peshawar following the Plan-Do-Study-Act (PDSA) methodology. The first cycle assessed baseline documentation compliance for six key parameters in ocular trauma examinations. A newly structured proforma and training intervention were then introduced. The impact of these interventions on documentation practices was assessed in the second cycle.
Results: Initial compliance rates were low for visual acuity (66.66%), extraocular movements (70.8%), visual fields (0%), and ocular diagrams (33.33%). Post-intervention, significant improvements were observed across all parameters: visual acuity (91.66%), extraocular movements (95.83%), visual fields (83.33%), and ocular diagrams (87.5%). Statistically significant improvements were seen in all four parameters (p

Key words: Ocular trauma, documentation, quality improvement, emergency department.