Einflussfaktoren und Kriterien für die forensische Dokumentationsqualität am Beispiel der Gewaltambulanz der Zentralen Notaufnahme der Universitätsmedizin Greifswald
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Media type:
E-Book;
Thesis
Title:
Einflussfaktoren und Kriterien für die forensische Dokumentationsqualität am Beispiel der Gewaltambulanz der Zentralen Notaufnahme der Universitätsmedizin Greifswald
Background: The standard documentation of clinical findings in case of violence victims is limited usable for medicolegal use. Our aim was to evaluate the current quality of documentation in such cases in multidisciplinary fashion and to evaluate possible solutions for this problem. Material und methods: We evaluated all patients who suffered violence from July 2010 till June 2014. A descriptive statistic overview-analysis of 572 patient cases has been performed. By literature research and expert opinion a checklist with forensic aspects for medicolegal evaluation was developed. Preselected study cases were evaluated with the developed checklist. Furthermore interdisciplinary opinions according to the quality of documentation were analyzed by a questionnaire based on the checklist. Results: In 45% of the preselected cases (n=100) the documentation was insufficient for medicolegal use, especially the documentation by photographs, of wounds and of special forensic aspects. Discrepancies in the documentation through the different disciplines trauma and forensic have been also registered. Discussion: The use of all information gained from judiciary evaluation, medical reports and clinical findings could optimize the quality of documentation in violence victims. Digitalization of findings from all possible sources in one database may be the right way in order to develop a thorough documentation form, compatible for medical use. Conclusion: The current trauma documentation in patients ...