Emergency department documentation in cases of intentional assault

Study objective: Emergency department records are an important source of in jury surveillance data. However, documentation regarding intentional assaul t has not been studied and may be suboptimal. The purpose of this study was to analyze physician documentation of assailant, site, and object used in intentional assault. Methods: The ED log of an urban Level 1 trauma center was retrospectively r eviewed to identify eligible patients presenting consecutively in November 1996. All acutely injured patients not involved in a motorized vehicle cras h were identified. Results: From the ED log, 1,483 patients were identified as possible study subjects; 1,457 (98%) charts were located and reviewed and 971 (67%) met in clusion criteria. Of these, 288 (30%) cases resulted from intentional assau lt. In 67% of patients, there was no documentation of the identity of the a ssailant. For 13% of cases, there was no documentation regarding the object or force used in the assault. in 79% of cases there was no documentation r egarding the site of assault. For 24 cases (8%), the assailant was document ed as an intimate partner or ex-partner. Police involvement in these cases was documented 54% of the time, despite the fact that this state mandates p olice reports for cases of acute partner violence. Social service involveme nt and shelter referrals were documented in less than one fourth of domesti c violence cases. Conclusion: Although the ED commonly treats patients who have been assaulte d, basic surveillance data are often omitted from the chart. Structured cha rting may provide more complete data collection.