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Discrepancy between severity obtained from examination and classification conducted by experienced examiners and
Christina L Calhoun1, Ross S Chafetz, M J Mulcahey
1Shriners Hospital for Children, Philadelphia, 19140, USA. ccalhoun@shrinenet.org
Objective:
The International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory examinations provides a mechanism for severity classification via the American Spinal Injury Association Impairment Scale (AIS). The purpose of this study is to explore agreement between reported severity in medical charts to severity determine via the International Standards examination and classification by trained examiners and classifiers.
Methods:
The agreement between severities from ISCSCI classification from experienced classifiers for all subjects was compared to severities from medical records using percentage agreement and the kappa statistic.
Results:
Severity classification between ISCSCI and medical record documentation was assessed for agreement in 157 subject examinations. Among the five medical records source documentation, agreement with the study ISCSCI classification on injury severity classification ranged from poor to high.
Conclusion:
The implication in this study provides justification for clinical practice guidelines and better documentation policy to improve documentation of injury severity.
