<< 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.)

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