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Expert Views on Using TraumaGram Illustrations

In forensic nursing, the necessity of comprehensive and accurate documentation extends beyond the electronic health record and examinations. A thorough and precise documentation of injuries and anomalies related to trauma, injury, and related examination findings has historically been challenging due to the use of non-descript “body grams” that were limited to anterior and posterior views of observed alterations.

In a quest to improve forensic nursing practice and related outcomes, the Academy of Forensic Nursing invested in the development and production of professional renderings of body grams to support a comprehensive and accurate pictorial documentation. Called TraumaGram™ illustrations, this documentation aid provides a variety of body surfaces and views to enable you, the professional, to illustrate your assessment and examination findings appropriately and specifically to support good clinical practices that ultimately improves patient outcomes and professional responsibilities.

A recent interview with Deb Holbrook, the clinical program director for forensic nursing at Baltimore City’s Mercy Medical Center, points out the features and clinical and programmatic outcomes achieved since using the AFN TraumaGram illustrations. Holbrook’s program historically used “body grams” in general nursing and medical practice over the years. From a quality-improvement perspective, the quality of the documentation along with general use and completion of the body grams was average at best.

General usage of body grams—while an accepted practice for documenting findings, anomalies, and incidental findings—have been looked at as being confusing, not always accurate, and limited given the anterior and posterior views of the full body. These body grams also had limited use given the need to reproduce the templates, resulting in blurred or poor-quality copies.

Since adopting the TraumaGram illustrations and implementing them in the Mercy Forensic Nursing Program, compliance with completing the documentation has improved while also improving the accuracy of the findings being recorded properly and specifically (accurate site or location being noted), which has aided the program in being effective and efficient in pictorial documentation.

Additionally, having the TraumaGram illustrations available to be printed on demand has impacted the accuracy and portrayal of the identified findings in a consistent and valid way that aids in correct interpretation of the findings with a positive response from detectives, prosecutors, and defense attorneys as a means of improving the quality of evidence being considered.

Holbrook indicates that from a quality-improvement perspective, the investment in the drawings has shown to improve the process of comprehensive documentation, while increasing the potential for accuracy and satisfaction of the nurses in completing the documentation. The forensic program ultimately has experienced overall improvement in efficiency, effectiveness of communicating and documenting findings from the exams, while advancing clinician satisfaction and compliance. Meeting this triple aim in forensic nursing keeps evidence-based nursing practice current and on-pace, said Holbrook.

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