Wound documentation is a vital skill, but it requires more training at both undergraduate and postgraduate levels, say researchers after a cross-sectional observational study of three academic emergency departments in the University of the Witwatersrand academic circuit, and published in the SA Medical Journal.
R Kleynhans, J du Plessis and P Moodley write that current training is also inadequate to equip doctors in the specialised field of medico-legal documentation and legal proceedings of the justice system.
Improved education, clearer protocols, templates, measuring tools and continuing professional development initiatives are needed, they say, and enhancing undergraduate training is key to preparing junior doctors to care for victims of interpersonal violence (IPV).
The trauma crisis in South Africa is witnessed daily by doctors working in emergency departments, and KwaZulu-Natal and the Western Cape are the only provinces with electronic trauma registries – a KZN study of data from one of these electronic registries found 1 263 847 ED visits for assault, gunshots and motor vehicle accidents from 2012 to 2022.
Intentional trauma exceeds non-intentional trauma with a ratio of 2:1.
A single-centre study in the Eastern Cape found that 42.2% of trauma-related ED visits were due to IPV.
Doctors are not only responsible for treating victims of IPV, but also need to record injuries to aid as evidence in legal investigations. The J88 form is a medico-legal document from the Department of Justice, and is unique to SA.
The first attending medical practitioner completes it. Kotzé et al and Müller et al have published articles with guidelines outlining how to complete the J88 form, aiming to improve documentation, and multiple studies have emphasised the importance of accurate documentation and its effect on criminal prosecution.
In a sensory ethnographic study by Mogale et al, prosecutors said: “(The) J88 is real and conclusive evidence because it is presented under Section 212 of the Criminal Procedure Act as amended.” Additionally, they stated that medical practitioners were not completing the J88 forms accurately.
A 2018 study of community service medical officers (CSOs) who had graduated from the University of the Free State (UFS) drew attention to their lack of training on medico-legal documentation. Only 26.8% of participants reported having had undergraduate training on completing the J88 form for assault cases.
Our study
This study aimed to assess the accuracy of wound documentation by doctors working in mixed medical and trauma EDs based on clinical findings documented on the J88 form, according to a simulated scenario.
Study sites included Helen Joseph Tertiary Hospital and two regional hospitals: Tambo Memorial Hospital and Thelle Mogoerane Regional Hospital. All three have mixed EDs with large trauma burden.
Moulage of various injuries was made by the primary investigator using silicone and a clothing mannequin limb. Six injuries were depicted: three stab wounds, one laceration, one bruise and one abrasion.
All injuries were described, measured and validated by two specialist emergency physicians and one trauma surgeon. A station was set up with the mannequin, and a short clinical scenario was given to the participants, who were given an information sheet. Informed consent was implied by the completion of the questionnaire and J88 form.
Participants were requested to complete a questionnaire and document injuries (as simulated by moulage on the mannequin) on a J88 form. Sections of the J88 form given for completion by participants were the clinical findings and the anatomical diagrams.
The questionnaire consisted of basic demographics, experience in the ED, how often participants manage IPV, frequency of J88 form completion, documentation of wound characteristics and participants’ impression of undergraduate and postgraduate training on wound documentation and measurement.
A total of 83 participants completed the J88 form, and 80 completed the questionnaire. Three participants gave no reason why they did not complete the questionnaire.
They rated their usual practice in terms of several aspects of wound documentation, from ‘never’ to ‘always’. Most of them self-reported that they ‘always’ document lacerations (82.5%), bruises (63.8%) and abrasions (62.5%), with little variability between participants’ answers.
While 71.8% of participants stated that they ‘always’ document stab wounds, 2.6% indicated that they ‘sometimes’ indicate these, 3.8% ‘rarely’ and 1.3% of participants indicated ‘never’. Participant answers had high variability ranging from ‘never’ to ‘always’.
Most (72.5%) reported that they ‘always’ document incisions, 2.5% ‘never’ document incisions and 7.5% stated that they did so ‘rarely’.
Most participants (42.5%) indicated that wound measurement is ‘always’ important, although they ‘never’ (20%), ‘rarely’ (41.3%) and ‘sometimes’ (35%) measure wounds to ensure accuracy.
According to the pre-set rubric, the average overall accuracy of wound documentation was 48%. The overall score for blunt force injuries was an average of 56%, and sharp force injuries scored 40.7%.
The accuracy of individual wound documentation was as follows: abrasion, 62.5%; laceration, 55.5%; bruise, 50%; stabs 1 and 3, 44.4%; and stab 2,33.3%. The location and size of the wound were documented by 98.8% (n=82) of participants across all wounds.
Most participants (89.2%, n=74) correctly signed pages 4 and 6 of the J88 form. One participant described an additional wound that was not part of the wound moulage. There was no statistically significant relationship between qualification, years qualified as a doctor and years of experience in the ED in improved wound documentation.
Wound size estimations
Wound size was underestimated in most large wounds (>5 cm length), but accurate in smaller wounds. There was a statistically significant under-estimation of abrasion length (p<0.001), abrasion width (p<0.001), bruise length (p<0.001) and laceration length (p<0.001).
Blunt force injuries were under-estimated, while sharp force injuries were accurate to within 2 mm.
Subgroup analysis of wound size estimations
There were no statistically significant differences between sexes, qualifications, or years since qualification as a medical practitioner. Perception of training Likert scale analysis was done, with a focus on central tendency.
Wound documentation training during undergraduate education was considered either ‘poor’ or ‘acceptable’ by 30% each of participants, ‘very poor’ by 18.8% and ‘very good’ by only 2.5%. Postgraduate wound documentation training was considered ‘very poor’ (34.2%) or ‘poor’ (43.4%) by most participants, with only 10.5% finding it ‘acceptable’, 9.2% ‘good’ and 2.6% ‘very good’.
Both undergraduate and postgraduate training in wound measurement was considered ‘poor’ or ‘very poor’ (70.5% and 84%, respectively).
Training gaps persist. Most study participants expressed that undergraduate training in wound documentation was ‘acceptable’ or ‘poor’, with postgraduate training as largely ‘poor’. Fouché et al found that while >65% of UFS medical school graduates had had prior training in general medico-legal and wound documentation, >73% had not received training specific to J88 completion.
Training encompasses medico-legal documentation in terms of overall accuracy and specific wound features.
Documentation remains poor. In our study, the overall average accuracy of wound documentation was 48%. Interestingly, we found that the description of blunt force injuries scored higher than that of sharp force injuries. This could be attributed to the study design and the Hawthorne effect. Other studies found that blunt force injuries were often missed or inadequately described.
Caution must be used when interpreting these data, as further studies are needed on the discrepancy between blunt and sharp force injuries. Despite the improved scoring of blunt force injuries, a sizeable proportion of bruises in our study were missed (25.3%), and it remains unclear whether including them would have improved scores.
Descriptions lacked key details. While participants self-reported that they often described the shape of injuries, <10% of them indicated the shape of sharp force injuries. Age and suspected mechanism of injury were recorded in <6% of injuries.
These findings are consistent with those of Loots et al, who also noted that specific wound characteristics, such as shape and age, were rarely documented.
Medico-legal documentation is an essential skill, yet as Mogale et al state, doctors document from a health and not a legal perspective. Current training is inadequate to equip doctors in the specialised field of medico-legal documentation and legal proceedings.
Improved education, clearer protocols, templates, measuring tools and continuing professional development initiatives are needed. Enhancing undergraduate training is key to preparing junior doctors to care for victims of IPV.
Study limitations
This was a small study, performed in academic regional and tertiary hospitals, and may not be reflective of the practices at smaller hospitals and community health centres. Convenience sampling was used.
The results will be shared with the Division of Emergency Medicine at the University of the Witwatersrand. The study and its findings will be presented at future academic meetings, and forwarded to the participating EDs.
Study details
R Kleynhans, MB ChB, DipPEC (SA); J du Plessis, MB ChB, FCEM (SA); P Moodley, MB ChB, FCEM (SA)Division of Emergency Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand.
Published in the SA Medical Journal on October 2025
Background
Medical doctors manage trauma cases daily, most needing medico-legal documentation. Wound documentation is a vital skill required by doctors.
Objectives
To describe and compare the knowledge and practices of documentation of clinical findings on the J88 form, looking at the accuracy of wound features and wound size estimation, focusing on participant gender, medical level of experience and type of injury simulated.
Methods
This was a multi-centre, prospective, observational, cross-sectional study of three academic emergency departments in the University of the Witwatersrand academic circuit using questionnaires, moulage and wound characteristic rubrics.
Results
Eighty-three doctors participated in the study. This was equally spread between sexes. According to wound rubrics, participants scored an average of 48% for accuracy of J88 form completion. The most precise wound description was abrasion (62.5%). The least precise wound description was stab wound (33.3%). Most participants (63.8%) noted on the questionnaire that they always indicate bruises; however, 25.3% missed the simulated bruise. The most frequently documented wound features were location and size estimation (98.8%). The least documented wound feature was the age and mechanism of the injury (<6%). Large wounds (>5 cm length) were underestimated (p<0.001), with accurate size estimations of smaller wounds (<5 cm). Perceptions of undergraduate training in wound documentation were evenly divided between acceptable and poor, while postgraduate training was generally regarded as poor.
Conclusion
This study found that wound documentation among emergency department doctors was poor, with participants scoring an average of 48% across the marking rubric. More training at both undergraduate and postgraduate levels is recommended.
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