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<0.05) using Paired samples t-tests.
Conclusion: Implementation of a structured proforma and targeted training significantly enhanced the documentation of ocular trauma examinations. This QIP demonstrates the effectiveness of simple interventions in enhancing documentation practices, potentially leading to improved patient care in ophthalmology emergency departments.

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