International Standards for Neurological Classification of Spinal Cord Injury: factors influencing the frequency, completion and accuracy of documentation of neurology for patients with traumatic spinal cord injuries

INTRODUCTION: We aim to evaluate the effects of injury-related factors and clinician training grades on the frequency, completion and accuracy of International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) charts in a tertiary care neurosurgery unit. MATERIALS AND METHODS: We retrospectively analysed 96 ISNCSCI charts of 24 traumatic spinal cord-injured (SCI) patients and 26 controls (vertebral fracture but neurologically intact), written by 50 clinicians. Seven components of each ISNCSCI charts (motor scores, sensory scores, sensory levels, motor levels, neurological level of injury, SCI severity and AIS) were reviewed to evaluate the effect of injury factors and clinician grade on the completion and accuracy of the ISNCSCI components. RESULTS: The ISNCSCI chart was used 1.9 times on average during admission. The number of ISNCSCI assessments was significant in those with isolated spinal injuries (p = 0.03). The overall completion and accuracy rates of the assessed ISNCSCI chart components were 39% and 78.1%, respectively. Motor levels and AIS had the lowest completion rates. Motor levels and sensory levels had the lowest accuracy rates. The completion rate was higher in the charts of male patients, tetraplegic patients, and in patients with isolated spinal injuries. The junior clinicians had a significantly greater ISNCSCI chart completion rate than their seniors. However, the senior clinicians were more accurate in completing the ISNCSCI chart components. CONCLUSION: The quality of ISNCSCI documentation remained poor regardless of the clinician training grade and injury factors. Clinicians should be educated on the ISNCSCI protocol and the importance of adequate documentation. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00590-019-02502-7) contains supplementary material, which is available to authorized users.