Clinical and Health Affairs
Patient Charting
Turning a Routine Activity into an Opportunity for Injury Prevention
By David McCollum, M.D., Sara Seifert, M.P.H., and Evelyn Anderson
ABSTRACT
Injuries can be predicted and prevented. The first step in doing so is gathering data about who was injured and how. Because injury data is based on documentation in patients’ medical charts, physicians play an important role in injury prevention. This article describes how to document all types of injuries, including those that are self-inflicted or caused by abuse.
Injuries, both those caused by acts of violence and those that are unintentional, account for more than 300,000 visits to Minnesota hospitals each year. Yet most injuries, whether intentional or not, can be predicted and prevented. Physicians play an important role in injury prevention.
By recognizing injuries and their cause, then providing complete, objective documentation in a patient’s hospital medical record, physicians help generate the data that lay the groundwork for effective prevention strategies and improved policies and legislation (Figure). For example, data gathered from hospital medical records by the Minnesota Department of Health about the impact of seat belt usage on the rate, type, and cost of motor vehicle-related injuries helped build a case for a new law enacted in 2009 that allows law enforcement officers to stop drivers only on the basis of not wearing a seat belt.
Patient charting is an essential first step toward collecting this information and, thus, preventing injuries. After you document an injury in a patient’s medical record, that information will be coded in two ways: one that describes the nature of the injury (for example, a closed fracture to the shaft of the clavicle) and another that indicates the intent and mechanism of the injury.
External cause of injury codes, known as e-codes, identify the intent (assault, unintentional, self-inflicted) as well as the specific mechanism that caused an injury (eg, a fall, motor vehicle crash, firearm, or burn). Injuries that involve the same mechanism (eg, poisoning) can have different intents (eg, self-inflicted or unintentional). E-codes also can indicate where an injury occurred (eg, on an escalator or stairs, at home, on the street), the object or weapon that caused the injury (eg, a handgun or a rifle), and who caused the injury (eg, a mother or spouse) (Table).
Coding information is used by hospitals for billing and internal analyses and by the Minnesota Department of Health for describing trends and risk factors for injury. Thus, the more detail you provide in the chart, the more information that is available for the coding and analyses that can lead to policies and programs to prevent injuries. This article describes how to document injuries, discusses special concerns related to abuse and self-inflicted injuries, and outlines legal concerns related to injury documentation.
Documenting Injuries
As documentation naturally flows from a physician’s interview with a patient or his or her family, it is important to ask the patient, a relative, or a witness certain questions. Whether the intent of the injury was unintentional, the result of abuse, or self-inflicted, the physician should find out the following:1 What happened? What was the mechanism of the injury—a motor vehicle crash, gunshot wound, or a fall, for example? What was the intent? Was it unintentional, assaultive, or self-inflicted? If someone else was involved in causing the injury, what was his or her relationship to the injured person? Where did the injury occur? At home, work, or school? On a farm or a road? Was it work-related? What was the date and time of the injury? What were the circumstances? Did the injury involve a weapon? Was alcohol or were drugs involved? Were there any unusual weather conditions that may have contributed? Was protective equipment such as a seat belt, airbag, helmet, or glove used?
Then, injury documentation should include the following:2
- A detailed description of the injuries, including type, number, size, location, and resolution. The location and nature of the injuries should be recorded on a body chart or drawing.
- The patient’s statement about what happened and who caused the injury, verbatim, in the case of an intentional injury. Writing that the patient said, “My husband hit me with a bat” is preferable to saying the patient has been abused. Rather than use the term “alleged,” write “patient stated” or “patient reported.”
- Your opinion about whether the injuries are consistent with the patient’s explanation.
- Your observations about the patient’s behavior, appearance, or any other indicators beyond what he or she says, particularly when the patient does not give complete information.
- Results of all pertinent laboratory and other diagnostic procedures.
- Color photographs and imaging studies, if applicable and if the patient gives consent to have photographs taken.
- The name and jurisdiction of the investigating officer, if the police were called, and any actions the police took of which you are aware.
- Information about the mechanism and intent of the injury should be included. Language should be objective and descriptive. When the physician’s opinion is included, it should be stated as such.
Between 22% and 35% of emergency room visits are related to ongoing intimate partner abuse, including many attempted suicides.3 Yet abuse and self-inflicted injury may not be obvious from the symptoms and conditions observed. If you suspect that an injury was self-inflicted or caused by abuse, you should tell why you believe this. You might write, “These injuries do not seem compatible with . . .” and explain how the patient’s description relates to your observation.
As with other types of injuries, the chart notes for those that are self-inflicted or the result of abuse should be objective, complete, and contain all relevant information provided by the patient or caregiver. Identifying intentional injuries is the first step toward making sure a patient gets appropriate care. Routine screening for abuse is the recommended standard of care.
Legal Concerns
When documenting an injury, you are not rendering a legal opinion about what happened but simply describing what you have seen and heard and giving your best medical judgment about what occurred. You may be concerned about becoming involved in a possible legal action. However, the real concern is if you fail to document abuse or self-inflicted injury. If the patient suffers later, you could be held liable. In addition, as a physician, you are a mandated reporter of suspected abuse involving children or vulnerable adults.
Documentation of injuries in the medical record is frequently reviewed by attorneys. When the documentation is complete and objective, attorneys are less likely to need further explanation, and you are less likely to be called to testify. Also, if if you have provided detailed information in the chart, you will be a more confident and better-prepared witness.
Conclusion
Earlier in the 20th century, when most medical professionals were family physicians in solo practice, medical records were small ledger cards with entries showing the dates of a patient’s visits, the medications prescribed, and the charges incurred.4 They reminded physicians of the details surrounding previous visits. Today’s medical records not only provide highlights for the documenting physician but also serve as a vehicle to communicate with other physicians and clinical staff, document diagnoses, enable accurate billing, and create a legal record. Increasingly, the medical record is also being used by public health officials to develop policies and programs that prevent injury and violence. MM
David McCollum is an emergency physician at Ridgeview Medical Center in Waconia. Sara Seifert was an epidemiologist with the Minnesota Department of Health, and Evelyn Anderson is a health educator in the Minnesota Department of Health’s Injury and Violence Prevention Unit.
The authors would like to acknowledge the Education Development Center, Inc., of the Injury Control and Emergency Health Services Section of the American Public Health Association for its development of the questions used for determining the cause of injury and provision of general information on coding external causes of injury.
REFERENCES
1. Christoffel T, Scavo Gallagher S. Injury Prevention and Public Health: Practical Knowledge, Skills and Strategies. Gaithersburg, MD: Aspen Publishers; 1999, p. 130. Available at: www.edc.org/newsroomarticles/injuy_not_accident. Accessed July 20, 2009.
2. Brown R. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion—Intimate Partner Violence. Chicago, IL: American Medical Association; 2002. Available at www.vahealth.org/Injury/projectradarva/documents/older/pdf/intpartvio_roadmap.pdf. Accessed July 20, 2009.
3. Pakieser RA, Lenaghan PA, Muelleman RL. Battered women: where they go for help. J Emerg Nurs. 1998;24(1):16-9.
4. Privacy Protection Study Commission: Record Keeping in the Medical-Care Relationship, in Personal Privacy in an Information Society: Report to President Jimmy Carter. July 12, 1977.
For More Information
For information on organizations that can provide training on identifying and documenting injuries related to violence, contact the Minnesota Department of Health Injury and Violence Prevention Unit at 651/201- 5484. |