Objective: To determine how often emergency department (ED) patients meeting the Centers for Disease Control and Prevention (CDC) mild traumatic brain injury (TBI) criteria were diagnosed with a mild TBI by the ED physician.
Design: Prospective identification of cases of mild TBI in the ED by study personnel using scripted interviews and medical record data was compared with retrospective review of ED medical record documentation of mild TBI.
Setting: EDs of a level I trauma center and an academic nontrauma hospital.
Participants: Prospective cohort of subjects (N=197; mean age, 32.6 y; 70% men) with arrival at the ED within 48 hours of injury, Glasgow Coma Scale score of 13 to 15, and injury circumstances, alteration of consciousness, and memory dysfunction consistent with the CDC mild TBI definition.
Interventions: Not applicable.
Main outcome measure: ED medical record documentation of mild TBI.
Results: Fifty-six percent of mild TBI cases identified by study personnel did not have a documented mild TBI-related diagnosis in the ED record. The greatest agreement between study personnel and ED physicians for positive mild TBI-related findings was for loss of consciousness (72% vs 65%) with the greatest discrepancy for confusion (94% vs 28%).
Conclusions: The diagnosis of mild TBI was frequently absent from ED medical records despite patients reporting findings consistent with a mild TBI diagnosis when interviewed by study personnel. Asking a few targeted questions of ED patients with likely mechanisms of injury that could result in mild TBI could begin to improve diagnosis and, in turn, begin to improve patient management and the accuracy of estimates of mild TBI incidence.