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Keywords:

  • documentation;
  • photography;
  • wound and injury

Abstract

Objective:  There is no widely accepted measure of clinical documentation quality in the ED. The present study creates a measure for comparing the quality of clinical documentation of external injuries with autopsy reports. This is used to discuss the advantages and disadvantages of introducing routine photography to improve clinical documentation of injuries.

Methods:  This retrospective case series addressed all non-surviving major trauma patients (Injury Severity Score ≥15) presenting to St. Vincent's Hospital ED, Sydney, within the 5 year period from 1 July 2002 to 30 June 2007. Comparison between clinical and autopsy documentation of external injuries was completed for each major trauma patient.

Results:  Of the 48 major trauma patients, there were an average of 11.6 injuries missed in documentation per patient (P < 0.001, 95% CI 8.6–14.6). ED documentation recorded on average 29% (95% CI 26%−32%) of the external injuries that appeared in the autopsy report. We call this percentage the external injury documentation rate. The external injury documentation rate was influenced by injury count and body region, but was not influenced by age, sex, severity (using the Abbreviated Injury Scale and Injury Severity Score), or whether the clinician used a trauma survey or standard progress notes or not, and there was no visible trend over time.

Conclusion:  Clinical documentation of external injuries in major trauma is poor. This is presumably because of many factors, including time pressures and high-stress environments. A possible strategy to improve this documentation is routine photography, which should offer both clinical and legal benefits.