Documentation of Extended Focused Assessment with Sonography in Trauma (eFAST) Is Frequently Incomplete: A...

The extended focused assessment with sonography in trauma (eFAST) is a point-of-care ultrasound protocol that identifies life-threatening thoracoabdominal trauma. Clinical documentation of the eFAST is essential to convey medical decisions, but the extent of documentation in clinical practice is unknown. This study describes the proportion of eFAST exams that are documented in the medical record, the type of documentation (free text vs procedure note), and clinical factors associated with documentation.

This prospective, single-center study evaluated the documentation of consecutive eFAST exams performed at a single Level I trauma center between November 2021-November 2022. Research coordinators observed all trauma activations and noted whether any portion of an eFAST was performed. Our primary outcome was the presence of any documentation in the chart. We analyzed secondary outcomes using a multivariable logistic regression model and included the type of documentation (any documentation vs billable procedure note) as well as patient- (body mass index, age, sex, shock index > 1, and presence of pathology on reference test) and operator-level (involvement of ultrasound faculty) factors associated with each type of documentation.

A total of 335 patients had a witnessed eFAST performed during the study period. No documentation was observed in 114/335 (34%) patients compared to any documentation in 221/335 (66%). Most documentation was free text only in 134/335 (40%) patients, with only 87/335 (25.9%) of patients with billable documentation. Regression analysis found that shock index > 1 (adjusted odds ratio [aOR] 7.37; 95% CI, 2.55-31.29), presence of pathology on eFAST (aOR 2.07; 95% CI, 1.24-3.51), and involvement of ultrasound section faculty (aOR 1.93; 95% CI, 1.05-3.66) were significantly associated with an increase in any documentation.

Approximately one-third of performed trauma eFAST exams are undocumented, and only one-quarter of exams have structured documentation that enables billing. Further work is needed to understand factors that can lead to improved documentation quality to communicate results, justify medical decision-making, and augment reimbursement.