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

Area of Science:

• Emergency Medicine
• Radiology
• Point-of-Care Ultrasound

Background:

• The extended focused assessment with sonography in trauma (eFAST) is crucial for identifying life-threatening thoracoabdominal trauma.
• Clinical documentation of eFAST exams is vital for communicating medical decisions, yet its extent in practice is largely unknown.

Purpose of the Study:

• To determine the proportion of eFAST exams documented in medical records.
• To analyze the types of documentation (free text vs. procedure note).
• To identify clinical factors associated with eFAST documentation.

Main Methods:

• Prospective, single-center study of consecutive eFAST exams at a Level I trauma center (November 2021-November 2022).
• Observation of trauma activations to record eFAST performance and documentation presence.
• Multivariable logistic regression to analyze factors associated with documentation type.

Main Results:

• 34% of eFAST exams lacked any documentation.
• Only 25.9% of patients had billable procedure note documentation.
• Shock index > 1, presence of pathology, and involvement of ultrasound faculty were associated with increased documentation.

Conclusions:

• A significant portion of trauma eFAST exams remain undocumented.
• Structured documentation for billing purposes is infrequent.
• Further research is needed to enhance documentation quality for improved communication, decision-making, and reimbursement.