Abstract
Purpose: The purpose of the study was to observe the frequency of complete documentation of the elements of the Ottawa Ankle Rules (OAR) in acute foot and ankle injuries in an emergency department with an electronic medical record. Procedure: Seven hundred patient visits for acute ankle/foot injuries were reviewed. Each component of the OAR was tabulated as positive, negative, or not documented. Radiograph ordering and results were collected. Descriptive statistics were calculated. Main Findings: Of the 700 charts evaluated, 663 received a radiograph, with 138 fractures identified. The OAR components were completely documented in 288 subjects (41%; 95% confidence interval, 37%-45%). One hundred percent of the charts documented weight-bearing status (template provided), but less than 0.5% (n = 3) documented a navicular examination (not mentioned on the template). Conclusion: Incomplete documentation of examination components is common, even with prompting from an electronic medical record. This engenders both medicolegal risk and an inability to perform quality analyses to minimize unnecessary radiograph use.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 999-1002 |
| Number of pages | 4 |
| Journal | American Journal of Emergency Medicine |
| Volume | 29 |
| Issue number | 9 |
| DOIs | |
| State | Published - Nov 1 2011 |
| Externally published | Yes |
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ASJC Scopus subject areas
- Emergency Medicine
Cite this
Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record. / Salazar, Luis; Best, Thomas; Hiestand, Brian.
In: American Journal of Emergency Medicine, Vol. 29, No. 9, 01.11.2011, p. 999-1002.Research output: Contribution to journal › Article
}
TY - JOUR
T1 - Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record
AU - Salazar, Luis
AU - Best, Thomas
AU - Hiestand, Brian
PY - 2011/11/1
Y1 - 2011/11/1
N2 - Purpose: The purpose of the study was to observe the frequency of complete documentation of the elements of the Ottawa Ankle Rules (OAR) in acute foot and ankle injuries in an emergency department with an electronic medical record. Procedure: Seven hundred patient visits for acute ankle/foot injuries were reviewed. Each component of the OAR was tabulated as positive, negative, or not documented. Radiograph ordering and results were collected. Descriptive statistics were calculated. Main Findings: Of the 700 charts evaluated, 663 received a radiograph, with 138 fractures identified. The OAR components were completely documented in 288 subjects (41%; 95% confidence interval, 37%-45%). One hundred percent of the charts documented weight-bearing status (template provided), but less than 0.5% (n = 3) documented a navicular examination (not mentioned on the template). Conclusion: Incomplete documentation of examination components is common, even with prompting from an electronic medical record. This engenders both medicolegal risk and an inability to perform quality analyses to minimize unnecessary radiograph use.
AB - Purpose: The purpose of the study was to observe the frequency of complete documentation of the elements of the Ottawa Ankle Rules (OAR) in acute foot and ankle injuries in an emergency department with an electronic medical record. Procedure: Seven hundred patient visits for acute ankle/foot injuries were reviewed. Each component of the OAR was tabulated as positive, negative, or not documented. Radiograph ordering and results were collected. Descriptive statistics were calculated. Main Findings: Of the 700 charts evaluated, 663 received a radiograph, with 138 fractures identified. The OAR components were completely documented in 288 subjects (41%; 95% confidence interval, 37%-45%). One hundred percent of the charts documented weight-bearing status (template provided), but less than 0.5% (n = 3) documented a navicular examination (not mentioned on the template). Conclusion: Incomplete documentation of examination components is common, even with prompting from an electronic medical record. This engenders both medicolegal risk and an inability to perform quality analyses to minimize unnecessary radiograph use.
UR - http://www.scopus.com/inward/record.url?scp=80855129663&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=80855129663&partnerID=8YFLogxK
U2 - 10.1016/j.ajem.2010.05.012
DO - 10.1016/j.ajem.2010.05.012
M3 - Article
C2 - 20674227
AN - SCOPUS:80855129663
VL - 29
SP - 999
EP - 1002
JO - American Journal of Emergency Medicine
JF - American Journal of Emergency Medicine
SN - 0735-6757
IS - 9
ER -