Childhood injuries and the importance of documentation in the emergency department

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Abstract
The purpose of this study is 1) to evaluate the extent to which documentation of the medical record is completed for dependent children who present for evaluation of an acute injury, and 2) to examine the factors that favorably or adversely influence completion of the medical record. The emergency department (ED) ledgers of 669 children less than nine years of age were reviewed, including 172 (25.7%) who presented for evaluation of an acute injury. Each of the latter charts was examined for basic demographic data, as well as information about injury type and mechanism, ED provider, and involvement of social services personnel. The ledgers were further examined to determine completeness of chart documentation in several relevant areas, including the circumstances and characteristics of the acute injury, pertinent past medical history, and course of management and referral while in the ED. Each of 15 individual documentation variables was assigned a score of either zero (incompletely/not addressed or documented) or one (completely addressed or documented). The 15 individual scores were equally weighted and summed, resulting in a total documentation score ranging from zero (failure to address or document any of the 15 variables) to 15 (all variables completely addressed/documented). The mechanisms of injury included 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 result of his injuries. Documentation of pertinent past medical history (prior hospitalization or surgery, compliance with routine well-child care, previous injuries or burns) was complete in 16,14, and 10%, respectively. Only 5% of ledgers contained a statement by a nurse or physician that reflected the appropriateness of the child's behaviors and interactions with his family or members of the health care team in the ED. More than 80% of charts included a complete description of the injury itself and the mechanism by which the injury occurred, documentation of ancillary data (when applicable), and information from consultation services when obtained. Consistency of the history and the presenting injury was addressed or implied in only 59% of ledgers, whereas documentation of associated injuries was completed in 38% of patient visits. For the purposes of this study, documentation was arbitrarily considered “acceptable” if more than half of the 15 documentation variables were completely addressed (total documentation score >7), a criterion 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 service 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 documentation; and 3) initiation of programs emphasizing parental education and injury prevention.

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