Emergency room records fail to note mild brain injuries, UW researchers report

Emergency room records fail to document the diagnosis of mild brain injury in more than half of cases, Seattle researchers report.

Failure to document the diagnosis in the chart can still cause problems because it may mean patients do not get needed follow-up care, education and rehabilitation or have the adequate documentation of the injury should they need it for legal or insurance reasons.

The symptoms of mild traumatic brain injury can be subtle: in some cases patients have only a brief period of amnesia, loss of consciousness or confusion. 

But even mild traumatic brain injury can be followed by difficulties with memory, concentration and emotional problems such as irritability that can last days, weeks, months and in some cases years.

Most cases of mild traumatic brain injury recover without long-term consequences, but 5-20% appear not to recover spontaneously.

In the paper lead author Janet Powell, Ph.D., an associate professor in the Department of Rehabilitation Medicine at the University of Washington, and colleagues speculate that emergency room workers are so focused on making sure that patients with head injuries do not have severe brain damage that they fail to include the diagnosis of mild brain injury in the medical records 56% of the patients with symptoms.

The study could not tell whether the emergency physicians correctly diagnosed mild brain injury in these patients. 

“All we know is whether or not a diagnosis was documented in the chart,” Professor Powell said in an email. “”They could have identified the problem and given appropriate education/advice to the patient, but not documented it.”

But failure to document the diagnosis in the chart can still cause problems because it may mean patients do not get needed follow-up care, education and rehabilitation or have the adequate documentation of the injury should they need it for legal or insurance reasons.

In the study, the team interviewed patients coming to the emergency departments of two Seattle hospitals who had injuries that might have caused affected the brain. 

Later, they reviewed the medical records of those who had had symptoms of mild traumatic brain injury to see if the injury had been noted as a diagnosis in the emergency room report.

The researchers suggest that emergency departments would be able to identify most patients with mild traumatic brain injury if they routinely asked patients a simple set of questions. 

Medics and ambulance personnel also proved very useful because they were often able to talk to people at the scene of the accident who saw the patient had lost consciousness or been confused after the accident or because they got to the accident scene early enough to see the patient experiencing these symptoms.

To learn more:

• Read our article on the Washington state’s initiative to help people with traumatic brain injury. 
• Go to the Washington State Brain Injury website. 
• Visit the National Library of Medicine’s information page on traumatic brain injury. 
• The article “Accuracy of Mild Traumatic Brain Injury Diagnosis” appears the Archives of Physical Medicine and Rehabilitation , the journal of the American Academy of Physical Medicine and Rehabilitation, but either a subscription or fee is required. 
• Read a 2005 review article on the diagnosis and treatment of mild traumatic brain injury in the journal Neuropsychiatric Disease and Treatment, which is available for free online.

Category: Brain & Nervous System, Emergency Medicine