CHILDHOOD INJURIES AND THE IMPORTANCE OF DOCUMENTATION IN THE EMERGENCY DEPARTMENT

The purpose of this study is 1) to evaluate the extent to which docume ntation of the medical record is completed for dependent children who present for evaluation of an acute injury, and 2) to examine the facto rs that favorably or adversely influence completion of the medical rec ord. The emergency department (ED) ledgers of 669 children less than n ine years of age were reviewed, including 172 (25.7%) who presented fo r evaluation of an acute injury. Each of the latter charts was examine d for basic demographic data, as well as information about injury type and mechanism, ED provider, and involvement of social services person nel. The ledgers were further examined to determine completeness of ch art documentation in several relevant areas, including the circumstanc es and characteristics of the acute injury, pertinent past medical his tory, and course of management and referral while in the ED. Each of 1 5 individual documentation variables was assigned a score of either ze ro (incompletely/not addressed or documented) or one (completely addre ssed or documented). The 15 individual scores were equally weighted an d summed, resulting in a total documentation score ranging from zero ( failure to address or document any of the 15 variables) to 15 (all var iables completely addressed/documented). The mechanisms of injury incl uded falls from height (48.3%), direct blunt impact other than falls ( 26.7%), penetrating injury (6.4%), burn (5.2%), and ingestion (8.1%). Seventeen patients (9.9%) were admitted for primarily medical, and one (0.6%) for primarily social, indications; one patient died as a resul t of his injuries. Documentation of pertinent past medical history (pr ior hospitalization or surgery, compliance with routine well-child car e, previous injuries or burns) was complete in 16, 14, and 10%, respec tively. Only 5% of ledgers contained a statement by a nurse or physici an that reflected the appropriateness of the child's behaviors and int eractions with his family or members of the health care team in the ED . More than 80% of charts included a complete description of the injur y itself and the mechanism by which the injury occurred, documentation of ancillary data (when applicable), and information from consultatio n services when obtained. Consistency of the history and the presentin g injury was addressed or implied in only 59% of ledgers, whereas docu mentation of associated injuries was completed in 38% of patient visit s. For the purposes of this study, documentation was arbitrarily consi dered ''acceptable'' if more than half of the 15 documentation variabl es were completely addressed (total documentation score >7), a criteri on met in only 33% of patient visits. ''Acceptable'' documentation was statistically related to injury type (P < 0.001), mechanism of injury (P < 0.018), and ED provider (P < 0.021). Perceived need for social s ervice referral did not influence completeness of chart documentation. Chart documentation of childhood injuries is inadequate. Suggestions to improve documentation include 1) identification of injury types and mechanisms, as well as family and individual characteristics that may suggest increased risk for negligent or abusive parenting practices; 2) establishment of ongoing educational programs in the ED that focus on risk assessment, case recognition and management, and ED ledger doc umentation; and 3) initiation of programs emphasizing parental educati on and injury prevention.