Injury coding in a national trauma registry: a one-year validation audit in a level 1 trauma centre

BMC Emergency Medicine

Table 3 Causes for missing and discordant AIS codes in the UNN trauma registry 2015

	Missing AIS code		Discordant AIS code
	AIS ≥ 2 ^b injury grades	AIS < 2 ^b injury grades	Injury not existing	AIS ^b injury grade discordant	AIS ^b injury grade concordant
Decided audit cause ^a						Total
Related to the patient record
Trauma registrar overlooked information	22	42				64
Trauma registrar misinterpreted information ^c	6	3	9	0	0	18
Trauma registrar chose incorrect AIS code ^d			0	26	22	48
Trauma registrar got information difficult to interpret			0	2	1	3
Trauma registrar used radiological DAI criteria ^e			0	2	0	2
Trauma registrar used NFS code instead of a more specified code			0	2	14	16
Trauma registrar coded injury but other AIS code chosen included the injury			6	0	0	6
Trauma registrar double coded injury by mistake			2	0	0	2
Related to the radiology report
Injuries not described	4	8				12
Injuries inaccurate described	3	0	7	8	12	30
Related to the AIS manual
AIS guide lacks code for cardiac arrest due to hypothermia			2	0	0	2
Related to other reasons
Physician described fracture not existing, radiology report correct			1	0	0	1

AIS Abbreviated Injury Scale, UNN University Hospital of North Norway, DAI diffuse axonal injury, NFS Not further specified, ^a Analysed on the level of each patient, each cause was counted only one time for each patient, ^b AIS Injury grade severity ranking 1–6, ^c Misinterpreted information corresponds to patient record information understood incorrectly, ^d Correct understanding of information but an incorrectly chosen code, for example, a mix of intracerebral contusion bleeding AIS code with the brain contusion code, ^e DAI criteria for radiological description do not fully comply with the DAI criteria in the AIS code manual

ISSN: 1471-227X