Medical documentation of burn injuries

Introduction

Medical documentation of burn injuries

For successful treatment of burns one of the most important pillars is an adequate documentation. Otherwise, nobody in science, economics or quality control can comprehend this issue’s complexity [22]. Research, science and costing in burns are based on accurate assessment and documentation of burn injuries. Documentation required, is time consuming and labor intensive. For any scientific comparability of burns the exact and correct extent and depth of burns are essential.

This simple looking issue is strongly influenced by the acting persons, which leads to a strong demand for the maximum objectivity that can be obtained. Quality of data, required to strengthen the evidence of burn treatment is very much dependent on objective description of the burn injury. Evidence requires comparable patients with comparable wounds and comparable and objective documentation.

Traditional documentation on paper is no valid alternative as requirements for extensive medical documentation are too complex. Among others [68] confirmed a qualitative and quantitative superiority of electronic to paper wound documentation.

Digital documentation provides better availability and assessment of collected data, easier exchange

Marc G. Jeschke et al. (eds.), Handbook of Burns

of information between experts and easier access to resources and so supports the creation of medical knowledge. By this, IT contributes remarkably to improvement of quality in management and treatment of burns. This can be of importance when applying admission criteria to burn centers with all their consequences for transport or primary treatment [61]. In particular, bigger amounts of existing information can only be handled successfully by modern computer aided documentation systems.

However, computer-assisted documentation alone does not necessarily create expedient data for scientific use. To ensure optimum evaluation of data, free text documentation needs to be avoided and the information recorded must be clearly structured and standardized [14, 62]. This allows for clear recording facts at a particular time, as for example patient’s conditions or single examinations. The quality of data can be improved by well-structured recording and an exact and uniform terminology allowing standardization. However, standardized information provided in this way will be less extensive than in free text documents [28].

Contents of an up-to-date burns registry

A modern and up-to-date documentation system should cover the following dataset:

Ethology of burns

Burn depth and size over the time

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