ADMISSION AFTER HEAD-INJURY - HOW MANY OCCUR AND HOW MANY ARE RECORDED

This study attempted to determine how many patients admitted with a he ad injury do not have the diagnosis recorded in the medical notes, and the factors associated with this failure. This observational study to ok place over four weeks with a review of notes of all patients in the trauma service admission wards in a District and Teaching hospital. A ll patients aged 16 years to 65 years admitted to the inpatient trauma wards were included, and the frequency of diagnosis of head injury ma de by the investigator was compared with the frequency of a recorded d iagnosis of head injury in the notes. Of 107 patients admitted 47 had had a head injury; 24 did not have the diagnosis recorded, and four of these had moderate or severe injuries. A failure to record diagnosis was more likely in the presence of other more severe injuries (21/28) and in patients with minor or trivial injuries (20/30). We conclude th at head injury registers are likely to miss a significant number of pa tients admitted to hospital unless specific attempts are made to ident ify and record the diagnosis. Copyright (C) 1996 Elsevier Science Ltd.