Wound documentation by doctors in academic emergency departments, Gauteng Province, South Africa
DOI:
https://doi.org/10.7196/SAMJ.2025.v115i9.3049Keywords:
Wound documentation, J88, medico-legal, Acute wound documentation, note keepingAbstract
Background. Medical doctors manage trauma cases daily, most needing medicolegal documentation. Wound documentation is a vital skill required by doctors.
Objectives. To describe and compare the knowledge and practices of documentation of clinical findings on the J88 form, looking at the accuracy of wound features and wound size estimation, focusing on participant gender, medical level of experience and type of injury simulated.
Methods. This was a multi-centre, prospective, observational, cross-sectional study of three academic emergency departments in the University of the Witwatersrand academic circuit using questionnaires, moulage and wound characteristic rubrics.
Results. Eighty-three doctors participated in the study. This was equally spread between sexes. According to wound rubrics, participants scored an average of 48% for accuracy of J88 form completion. The most precise wound description was abrasion (62.5%). The least precise wound description was stab wound (33.3%). Most participants (63.8%) noted on the questionnaire that they always indicate bruises; however, 25.3% missed the simulated bruise. The most frequently documented wound features were location and size estimation (98.8%). The least documented wound feature was the age and mechanism of the injury (<6%). Large wounds (>5 cm length) were underestimated (p<0.001), with accurate size estimations of smaller wounds (<5 cm). Perceptions of undergraduate training in wound documentation were evenly divided between acceptable and poor, while postgraduate training was generally regarded as poor.
Conclusion. This study found that wound documentation among emergency department doctors was poor, with participants scoring an average of 48% across the marking rubric. More training at both undergraduate and postgraduate levels is recommended.
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