Original Paper: Data-assisted review of medically treated injuries in general practice

Abstract

Objectives: To automate the recording and reporting of information relevant for reviewing injuries caused by accidents, violence and self-infliction, based on electronic medical records in general practice.

Methods: Contacts in general practice in five strategically selected municipalities in Norway were used in a standardised and prospective recording of treated injuries. Twenty-two general practitioners with a total population of 23,240 persons participated. An accident-recording module fully integrated in the electronic medical records system was designed and programmed to be triggered when an injury diagnosis was made. Pop-up windows followed initiation and elicited further information from the general practitioners. A floppy disk was programmed to generate a population-based report with a standard set of tables. The results were compared with earlier manual recordings on paper. The main outcome measures were proportions, crude and specific rates of new injuries and sorted qualitative descriptions of the accident courses and the injury mechanisms.

Results: During 229 days, 1270 injuries were recorded (87 per 1000 inhabitants per year); five per 1000 were intentional. The majority of the unintentional injuries were home accidents (37%), occupational accidents (16%) and athletics/sports accidents (10%). Most frequent diagnoses were sprains and strains (34%), skin penetrations (24%) and fractures (14%). Five percent of the treated persons were under the influence of alcohol, 15% were given a sick-leave certificate and 6% were referred to hospital. Most patterns were similar in all the municipalities.

Conclusions: The integrated computerised accident surveillance module gave reliable numbers and was timesaving, taking advantage of other information in the electronic medical records. It was well accepted by the general practitioners and gave sound premises for local preventive efforts. We believe that the method is applicable to assessing needs in other fields and studying general practice activities.

Key Words:

• injuries
• accident surveillance
• family practice
• prevention
• electronic patient records
• data-assisted review