| Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record. | |
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MedLine Citation:
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PMID: 20674227 Owner: NLM Status: In-Data-Review |
Abstract/OtherAbstract:
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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. |
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Authors:
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Luis Salazar; Thomas M Best; Brian Hiestand |
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Publication Detail:
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Type: Journal Article Date: 2010-08-01 |
Journal Detail:
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Title: The American journal of emergency medicine Volume: 29 ISSN: 1532-8171 ISO Abbreviation: Am J Emerg Med Publication Date: 2011 Nov |
Date Detail:
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Created Date: 2011-11-14 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 8309942 Medline TA: Am J Emerg Med Country: United States |
Other Details:
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Languages: eng Pagination: 999-1002 Citation Subset: IM |
Copyright Information:
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Copyright © 2011 Elsevier Inc. All rights reserved. |
Affiliation:
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Department of Family Medicine, The Ohio State University Medical Center, Columbus OH 43201, USA. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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