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.