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The Quantity of Cause‐of‐injury Information Documented on the Medical Record: An Appeal for Injury Prevention
Author(s) -
Schwartz Robert J.,
Boisoneau David,
Jacobs Lenworth M.
Publication year - 1995
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/j.1553-2712.1995.tb03168.x
Subject(s) - medicine , medical record , medical emergency , medical information , emergency department , medical history , emergency medicine , family medicine , nursing , surgery
Objective: To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e‐codes. Methods: Quantitative “stages of information” were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause‐of‐injury information categories. Results: Information was obtained from 109 patients. Only 46% of the cause‐of‐injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause‐of‐injury information. Conclusions: Emergency providers obtain significantly less cause‐of‐injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause‐of‐injury information than was obtained during the patient interview.