Abstract
Injury data in the paper medical record are often inaccurate or lack adequate specificity to evaluate trauma patient care. To improve the quality of recorded injury data, we are testing a graphical, anatomic-based interface for quick collection of detailed injury information directly from the trauma physician. Navigation and data collection throughout the interface are facilitated by anatomic illustrations, menus, lists, and "dialog boxes". Using a "point and click" method, the user selects a specific anatomic structure (i.e., the spleen) from drawings. Detailed injury information, specific to the selected structure, is then collected from the user in an "intelligent" modal dialog box. The software uses SNOMED III nomenclature to create and store ICD, AIS, and trauma registry codes for each injury. Users can review and print abbreviated and detailed injury information for each patient. This demonstration will walk viewers through the injury collection and review process for injuries to the abdomen. We plan to evaluate the interface for accuracy, speed, user satisfaction and resources expended by comparing it with current methods of data collection and injury coding at our level I trauma facility.
Full text
PDF
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Bishop C. W. A new format for the medical record. MD Comput. 1991 Jul-Aug;8(4):208–215. [PubMed] [Google Scholar]
- Cushing B. M., Teitelbaum S. D., Burman W., Karges D., Bame W. Injury severity: better data through direct physician entry of anatomic injuries? Med Decis Making. 1991 Oct-Dec;11(4 Suppl):S45–S48. [PubMed] [Google Scholar]
- Dunham C. M., Cowley R., Gens D. R., Ramzy A. I., Rodriguez A., Belzberg H., Wiles C. E., 3rd Methodologic approach for a large functional trauma registry. Md Med J. 1989 Mar;38(3):227–233. [PubMed] [Google Scholar]
- MacKenzie E. J., Shapiro S., Eastham J. N. The Abbreviated Injury Scale and Injury Severity Score. Levels of inter- and intrarater reliability. Med Care. 1985 Jun;23(6):823–835. doi: 10.1097/00005650-198506000-00008. [DOI] [PubMed] [Google Scholar]