Feasibility of Using Electronic Medical Records to Identify Postdischarge Mental Health Screening Documentation in Trauma Patients.

BACKGROUND

Injury leads to long-term physical and mental health challenges, yet inpatient screening for post-traumatic stress disorder and depression remains inconsistent, and postdischarge mental health is poorly understood, particularly in less resourced trauma centers where emerging symptoms may go unrecognized.

OBJECTIVE

To evaluate the feasibility of using the electronic medical record to identify postdischarge mental health screening documentation in adult trauma patients within 6 months after discharge.

METHODS

This retrospective descriptive feasibility study was conducted at a midwestern US regional Level II trauma center serving a predominantly rural catchment area. Adult trauma patients admitted between January 1 and December 31, 2024, were eligible for inclusion. A stratified sampling strategy was used, selecting up to 4 records per month, with follow-up data collected for 6 months postdischarge.

RESULTS

The final sample included 48 patients with a median age of 67 (IQR: 18) years, predominantly male (n = 35, 73%), and White (n = 40, 83%). A total of 7 patients (15%) screened positive for post-traumatic stress disorder risk, depression risk, or both during inpatient admission. Trauma-related follow-up was documented in the electronic medical record for 37 patients (77%), with a median of 15 days (IQR: 16) to first follow-up appointment and a median of 2 provider contacts (IQR: 1) within 6 months of discharge. Despite this follow-up, only 1 of 37 patients (3%) with documented follow-up had a documented mental health screening during the postdischarge period.

CONCLUSION

This feasibility study found that the electronic medical record alone was insufficient to capture postdischarge mental health screening documentation, with only 1 screening identified across 37 patients with documented follow-up, highlighting a critical gap in care continuity that warrants further investigation.