When & How To Document Injuries


Accurate and proper medical documentation promotes patient safety and patient care. Just like documenting any disease or health condition, proper documentation of injuries is also important. When a patient gets injured from an accident or fall, it needs to be accurately documented with the help of a medical transcription company. It allows healthcare providers to monitor what has been done, provide better care, and this also minimizes the chances of patients returning to the hospital.

Accurate and proper documentation of injuries facilitates better patient care, reduces errors and keeps providers informed about a patient’s condition. It also helps to protect the doctors from any legal issues. The following are some features of effective injury documentation.

  • Provides access to factual, consistent, and accurate input
  • Updates the information after any recordable event
  • Ensures all information is current
  • Makes sure that all entries are legible and signed
  • Eliminates meaningless jargon, phrases or abbreviations that aren’t commonly understood

Poor Injury Documentation

There are many factors that can contribute to poor injury documentation. Anything that hinders the recording of patient information or poor communication between healthcare professionals can lead to poor documentation of injuries. Poor record keeping involves:

  • Incorrect entries
  • Spelling mistakes
  • Lack of clarity in entering data
  • Copying and pasting
  • Missing data
  • Failing to correct incorrect data in a timely manner
  • Use of incompetent service provider for medical documentation who does not understand medical jargon.

Recommendations for Proper Injury Documentation

The following are some of the tips to ensure clear and accurate injury documentation.

  • Always remember that whoever is reviewing the medical record may not have the depth of knowledge of the person who made the entry
  • Ensure that all healthcare providers understand the patient’s limitations
  • Make sure to record the current status and condition of the patient in the EHR
  • Confirm that the EHR states an objective story of the patient
  • The entries should reflect the level of care the patient is receiving
  • Record how and why a patient’s health is improving
  • Make sure that all entries are understandable and coded properly
  • The documentation should include patient and family directions
  • Make certain that all entries comply with regulatory, licensure and quality standards
  • If you are using a transcription facility, then ensure that they are US-based services who understand the context and can transcribe the medical jargon.

How to Take Daily Session Notes for Injuries and When It Should Be Complete

Daily session notes help to record all the services that you provide to the patient. Since it is recorded on a daily basis, it allows healthcare professionals to go through these session notes and plan for ongoing care. Consistent and accurate documentation serves as evidence about the assessment of the treatment and progress of service for a patient. This document shows the communication between healthcare providers. This helps those who receive documentation to be aware of any provider, client or family involvement in the daily session. It can also serve as required evidence for insurance companies to ensure you are properly reimbursed for the services rendered.

Some advantages of daily session notes:

  • Act as a legal protection for clients, practitioners and the practice
  • Can be used for data and research
  • Helps you with correct medical coding
  • Allow faculty to train and provide quality assessment and review of staff practices
  • Help with optimal care of the client

Now that it is clear how to draft daily session notes, the next step is to understand when the notes should be complete. The daily session notes should be completed in seven days from the date of service. The discharge summary should be completed within 30 days of discharge. It is important to know the state and federal policies for the service area.

With advanced technologies, there are new and advanced ways for healthcare providers to monitor and treat injured or ill people. They can rely on medical transcription services to ensure timely injury documentation. These services also have trained medical transcriptionists who are specialized in areas like pathology transcription, orthopedic transcription, cardiology transcription and other medical specialty transcription.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.