Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record.

摘要

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.