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<< Ballistic Injuries In The Emergency Department (Trauma CME)

Documentation Of Gunshot Wounds

Emergency clinicians are uniquely situated to observe and record ballistic injuries before the wounds are disturbed by surgical or medical intervention. While documentation is very important for both medical and legal purposes, documentation should not compromise patient care or interrupt resuscitation efforts. When done properly, ballistic documentation can be performed quickly and accurately, but many EDs do not focus on the documentation aspect of ballistic injury. One study found that of 93 gunshot wounds treated at a Level I trauma center, the wound size was documented only 8.6% of the time. Additionally, wound shape was documented only 1% of the time, and anatomic location was documented only 39.8% of the time.130 Implementation of an easy-to-use, standardized gunshot wound description form was found to drastically improve gunshot wound documentation in this same trauma center.130 (See Figure 4 and Figure 5.)

Proper documentation of a gunshot wound includes the anatomic location, size, shape, and characteristics of the wound. Emergency clinicians should avoid speculating on the caliber of weapon or bullet type that caused the wound. In addition, wounds should not be described as “entrance” or “exit,” because this determination can be very difficult to make.131 Other characteristics of the wound should be described such as burns, bruising, abrasions, or soot around the wound edges. Carbonaceous material around the wound should be described as “soot.” The term “powder burn” is no longer considered accurate or appropriate terminology.131 Medical photography is an easy and accurate way to document ballistic injury. Consent must be obtained prior to obtaining pictures, and most hospitals have specific protocols addressing medical photography, which must be followed. Place a ruler in the photograph to provide a scale of measurement. If a ruler is not available, use a standard-sized, well-known object such as coin.132 All documentation should be purely factual. The emergency clinician should avoid recording any speculation or opinions in the medical chart. If the patient expresses an opinion that is pertinent to the record, this should be recorded in the patient’s own words and in quotation marks. Remember that the medical chart is a legal document and may be used as evidence in a criminal trial.

 
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Last Modified: 07/19/2018
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