The hospital record of the injured child and the need for external cause-of-injury codes

Proper record-keeping of emergency department visits and hospitalizations o f injured children is vital for appropriate patient management. Determinati on and documentation of the circumstances surrounding the injury event are essential. This information not only is the basis for preventive counseling , but also provides clues about how similar injuries in other youth can be avoided. The hospital records have an important secondary purpose; namely, if sufficient information about We cause and mechanism of injury is documen ted, it can be subsequently coded, electronically compiled, and retrieved l ater to provide an epidemiologic profile of the injury, the first step in p revention at the population level. To be of greatest use, hospital records should indicate the "who, what, when, where, why, and how" of the injury oc currence and whether protective equipment (eg, a seat belt) was used. The p ediatrician has two important roles in this area: to document fully the inj ury event and to advocate the use of standardized external cause-of-injury codes, which allow such data to be compiled and analyzed.