Poor trauma documentation — how to spot it and how to talk about it with providers


Good trauma data starts with good documentation. When providers fail to document care accurately, the trauma registry ends up with lower quality data. This can undermine trauma quality and PI initiatives, and it can also reduce trauma program reimbursement.

In our experience, there are two keys to improving trauma documentation — knowing how to spot under-documentation and knowing how to talk to trauma providers about documentation gaps.

Signs of poor trauma documentation

In most instances, poor trauma documentation is a failure to document injuries and complications as specifically as possible. The majority of problems fall into three specific injury categories:

Closed head injury. If a provider documents “closed head injury” with no other information, the appropriate Abbreviated Injury Scale (AIS) descriptor is “head injury, not further specified.” This will yield an AIS value of 9 (not specific), which does not generate an Injury Severity Scale (ISS) value.

Most head injury cases should have more detail. Focus on two questions:

  • Did the patient suffer a concussion? Convincing evidence of head injury coupled with a medical diagnosis of concussion will generate an ISS of 1. If adequate documentation is missing from the physician history and physical (H&P), check the discharge note.
  • Did the patient experience loss of consciousness? Properly documented loss of consciousness (LOC) can increase the ISS significantly. Remember that self-report or bystander report is insufficient. To be included in the trauma registry, LOC must be observed by a physician, physician assistant, nurse practitioner or prehospital provider and documented in the medical record. Adequate documentation will also include time parameters. Brief LOC yields an ISS of 4, while LOC between 1 and 6 hours will generate an ISS of 9.

Blunt chest injury. If a provider documents “blunt chest injury” with no other details, the appropriate AIS descriptor is “injury to thorax, not further specified.” Again, this will not generate an ISS score. Documentation of rib fracture is helpful, but “multiple rib fractures” with no further specifics will generate an ISS of only 4.

Once more, there is almost always more detail that can be captured. The key questions are:

  • How many ribs were fractured? If 3 or more ribs were broken, the appropriate AIS code will generate an ISS of 9.
  • Does the injury qualify as flail chest? If the patient has flail chest involving 6 or more ribs, the ISS is 16. If the diagnosis is bilateral flail, the ISS will be 25.

Blunt abdominal injury. The story is the same — documentation of “blunt abdominal injury” alone translates into an ISS of zero. Explore three questions:

  • Did the patient suffer a contusion of the abdomen? Check the H&P, the ED provider notes or even the EMS report to see if any provider documented contusion.
  • Were there any hematomas? Again, provider documentation might be available in the provider H&P or notes from the ED or EMS.
  • Were there any abrasions? While abrasions are often missing from the medical record, they may be documented in the EMS trip sheet.

While these injuries yield very small ISS scores, the cumulative effect can be significant — especially if multiple body regions are affected. The key point is that registrars should search the documentation for contusions, hematomas and abrasions and follow up with providers if this information is missing.

Strategies for communicating with trauma providers about documentation

When you suspect under-documentation, trauma registrars and registry managers need to follow up with trauma surgeons and advanced practice providers (APPs) to clarify. This may sound challenging, but remember that most trauma providers are very interested in capturing good data. Here are three strategies for communicating effectively about trauma documentation:

1. Provide guidance. In most cases, trauma providers under-document because they do not understand the mechanics of AIS coding. Be ready to explain how different documentation wording drives different AIS codes and ISS scores. In some cases, you can provide very helpful guidance on where providers can get the information they need to document more accurately. For example, when documenting blunt chest injury, surgeons or APPs will often refer to the impression of the radiology report, which typically summarizes findings as “multiple rib fractures.” Instead, providers need to review the body of the radiology report. The report body will typically specify which ribs were fractured and provide other important information.

2. Create a query process. It makes sense to create a standard process for handling documentation queries. First, create parameters for when to query a provider. A parameter might be as simple as “Query the provider for any NFS (not further specified) code.” Second, create query template for common documentation questions. As a starting point, you can use the questions listed above as prompts for capturing further information on head, chest and abdominal injuries.

3. Collaborate with other coding experts. If your hospital employs clinical documentation specialists, work with them to address trauma documentation issues. Many of these specialists will be able to tackle injury documentation in the context of both data quality and revenue optimization. Trauma registry leaders should also build links with the inpatient coding department. Injury coding and reimbursement coding are very different, but there is an opportunity to collaborate to meet common goals. Start by meeting with the supervisor of medical records. Identify the trauma documentation issues faced by both registrars and inpatient coders. Then create a plan for educating trauma providers on how to document injuries as accurately and specifically as possible.

Mike Trelow, CSTR is vice president of operations at Pomphrey Consulting. Stacey Hairston, MHA, RHIA is the ICD-10-CM/PCS content expert at Pomphrey Consulting. She is also assistant professor of health information technology at Southwestern Illinois College.

Pomphrey Consulting has been providing virtual educational courses since 2013. For a full list of courses and webinars, visit www.pomphreyconsulting.com. We offer a wide range of training opportunities for both registrars and trauma program managers. We also offer trauma center management services like registry staffing and trauma service consulting.

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