Trauma patients without a trauma diagnosis: the data gap at a level one trauma center

Trauma registries may contain records without a codable trauma diagnosis, creating a "data gap" that multiplies the number of invalid registry data fields. We designed an investigation intended to determine the incidence of registry records with noncodable trauma diagnoses, characterize those records, and determine the reasons for inadequate diagnosis data.

We used a retrospective cohort design. A query of trauma registry records spanning a 5-year period yielded 129 records with no injury severity score. Each patient's medical record was reviewed, sources of diagnostic information were noted, and diagnoses were categorized.

In 57% of cases, we found documentation that the patient had sustained an injury, but the injury was inadequately documented in the discharge summary. In 19% of cases, although the registry record was valid, the diagnosis was not codable as trauma. In 17% of cases, clinical documentation was adequate, but the diagnosis was inadequately recorded in the trauma registry. In 13% of cases, no traumatic injury was sustained, although the registry record was valid. In 2% of cases, the trauma registry record itself was invalid. In 1% of cases, a coding error occurred. Particularly prominent among records with inadequate discharge documentation were cases of head and spine injury for which there was no radiographic evidence.

The incidence of records with noncodable diagnoses might best be reduced through improved physician documentation, revision of trauma registry inclusion criteria, increased attention by trauma registrars to key sources of documentation, and direct communication with the attending physician when necessary.