Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt

Abstract

Trauma records in Egyptian hospitals are widely suspected to be inadequate for developing a practical and useful trauma registry, which is critical for informing both primary and secondary prevention. We reviewed archived paper records of trauma patients admitted to the Beni-Suef University Hospital in Upper Egypt for completeness in four domains: demographic data including contact information, administrative data tracking patients from admission to discharge, clinical data including vital signs and Glasgow Coma Scale scores, and data describing the causal traumatic event (mechanism of injury, activity at the time of injury, and location/setting). The majority of the 539 medical records included in the study had significant deficiencies in the four reviewed domains. Overall, 74.3% of demographic fields, 66.5% of administrative fields, 55.0% of clinical fields, and just 19.9% of fields detailing the causal event were found to be completed. Critically, oxygen saturation, arrival time, and contact information were reported in only 7.6%, 25.8%, and 43.6% of the records, respectively. Less than a fourth of the records provided any details about the cause of trauma. Accordingly, the current, paper-based medical record system at Beni-Suef University Hospital is insufficient for the development of a practical trauma registry. More efforts are needed to develop efficient and comprehensive documentation of trauma data in order to inform and improve patient care.

Clinical emergency care quality indicators in Africa: a scoping review and data summary

“… 57–94 The second group included 15 publications, which were cited above as containing ‘AFEM-CC quality indicators exact match’ data, but which contained additional ‘AFEM-CC quality indicators near match’ data. 22 25 26 28 29 31 33 34 39 41 45 46 54–56 This brings the total number of publications containing ‘AFEM-CC quality indicators near match’ data to 53 and the total number of data points identified within those publications to 87. Tables 2 and 3 contain summary ‘AFEM-CC quality indicators near match’ data, while further detail about each included publication is provided in online supplemental appendix 3 .…”

“…In total, 39 studies were seen to contain ‘AFEM-CC quality indicators exact match’ data for process clinical and/or outcome quality indicators 18–56. Only 8% (3 of 39) of these studies explicitly mentioned quality in the stated research objectives.…”

“…The first group included 38 publications, which were identified as containing only ‘AFEM-CC quality indicators near match’ data 57–94. The second group included 15 publications, which were cited above as containing ‘AFEM-CC quality indicators exact match’ data, but which contained additional ‘AFEM-CC quality indicators near match’ data 22 25 26 28 29 31 33 34 39 41 45 46 54–56. This brings the total number of publications containing ‘AFEM-CC quality indicators near match’ data to 53 and the total number of data points identified within those publications to 87.…”

Feasibility study of the Utstein Style For Drowning to aid data collection on the resuscitation of drowning victims

“…However, clinical documentation, even in patients with cardiac arrest 33 and especially with children 34 , 35 has long been recognised as an issue. This problem is more significant in low resource settings, 36 , 37 which also bear the largest burden of drowning globally. 1…”

Challenges to the development of the trauma system in Egypt

“…in a study reviewing 539 medical records for trauma patients at Beni-Suef university. 37 The study clearly showed significant defects in 4 studied criteria, including demographic data, administrative fields, clinical description of injury, and the casualty event, which was concluded to be inadequate for developing trauma registry data.…”