The Completeness of Documentation in Non-Severe Trauma Patients: A Forensic Aspect

The Completeness of Documentation in Non-Severe Trauma Patients: A Forensic Aspect

The main objectives of this study are to evaluate the completeness of wound documentation and to evaluate missed injury from the Emergency Department (ED) in non-severe trauma patients for quality improvement in both clinical and forensic purposes. The medical records were retrospectively reviewed to compare the injury documentation between the ED and Clinical Forensic Medicine (CFM) unit. The injury documentation rate (IDR) was calculated to represent the adequacy of total number of wounds recorded.