Background: Documentation of the clinical course of a compartment
syndrome is critical to effective treatment; however, such documentation often
is found to be inadequate.
Methods: Notes and consent forms for thirty consecutive patients
with adequate follow-up who had undergone fasciotomy for the treatment of
compartment syndrome were reviewed for legibility, notation of the time and
date, and documentation of the presence of core physical examination and
history findings, including pain, paresthesias, tenseness, pain on passive
stretch, sensory deficit, motor deficit, pulses, compartment pressures, and
diastolic blood pressure.
Results: Documentation was inadequate for twenty-one patients (70%):
the notes and consent forms were not timed or not dated (or both) for nine
patients (30%), and the notes were at least partially illegible for sixteen
patients (53%). The documentation was incomplete with regard to the presence
of paresthesias in eleven patients, pain on passive stretch in ten, sensory
deficit in nine, motor deficit in eight, pulses in seven, pain in five, and
tenseness in three. The documentation was incomplete with regard to the blood
and compartment pressures for sixteen and six patients, respectively.
Conclusions: The documentation of the core history and physical
examination findings was inadequate in this series of patients with
compartment syndrome. On the basis of the results of this study, and through
an organizational systems approach, we have instituted for our residents,
nursing staff, and faculty an educational program on the documentation of
compartment syndrome in patients who are at risk for this condition.