Discrepancy between severity obtained from examination and classification conducted by experienced examiners and classifiers and documented severity in paediatric spinal cord injury.
OBJECTIVE
The International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory examinations provides a mechanism for severity classification via the American Spinal Injury Association Impairment Scale (AIS). The purpose of this study is to explore agreement between reported severity in medical charts to severity determine via the International Standards examination and classification by trained examiners and classifiers.


METHODS
The agreement between severities from ISCSCI classification from experienced classifiers for all subjects was compared to severities from medical records using percentage agreement and the kappa statistic.


RESULTS
Severity classification between ISCSCI and medical record documentation was assessed for agreement in 157 subject examinations. Among the five medical records source documentation, agreement with the study ISCSCI classification on injury severity classification ranged from poor to high.


CONCLUSIONS
The implication in this study provides justification for clinical practice guidelines and better documentation policy to improve documentation of injury severity.
Calhoun
Christina L
CL
Shriners Hospital for Children, Philadelphia, 19140, USA. ccalhoun@shrinenet.org
Chafetz
Ross S
RS
Mulcahey
M J
MJ
D000293:Adolescent; D002648:Child; D004185:Disability Evaluation; D004282:Documentation / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D010808:Physical Examination; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D013119:Spinal Cord Injuries / Q000145:classification*