Trauma care documentation: a comprehensive guide

The medical record serves numerous functions. It provides chronologic evidence of patient evaluation, treatment, and response to therapy, and a means to review the quality of the care. Communication among members of the health care team regarding the patient's status and plan of care also occurs by means of the medical record. The medical and legal importance of a comprehensive, accurate trauma resuscitation record cannot be overemphasized. The success of this type of documentation will depend on the design of the record and the understanding of the personnel involved. In addition, nursing managers responsible for the fiscal accountability of their departments understand the value of accurate documentation. The trauma resuscitation record can be used to demonstrate to insurance companies the reason for charging trauma patients additional fees. Inadequate documentation can cause charges to be disallowed by the third-party payors. Perhaps one of the most important functions of the medical record is to assist in protecting the legal interest of the patient and the health care provider. Minimum documentation for care provided in the emergency department must include patient identification, how the patient arrived, care that was rendered before arrival, pertinent history, chronologic notation of results of physical examination including vital signs, and the results of diagnostic and therapeutic procedures and tests. The physician's orders and diagnostic impression should be recorded. It is important that the patient's response to the interventions, not just the intervention itself, be described. The patient's disposition and condition on discharge from the emergency department must be documented. For the trauma patient, mechanisms of injury, GCS, trauma score (or essential components), spinal immobilization, and the status of airway, breathing, and circulatory systems also must be recorded. The importance of accurate and comprehensive documentation on every medical record should not be underestimated. (National Standards of Emergency Nursing Practice dictate that nurses are responsible for the accurate documentation of patient care.) The medical record provides both important information about the patient's clinical condition and the corner-stone for lawsuits in alleged medical negligence. It is the legal documentation of ongoing patient care delivery and the chronicle of the patient's responses to therapeutic interventions.