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

Zeinab Mohammed, Ahmed Arafa, Shaimaa Senosy, El-Morsy Ahmed El-Morsy, Emad El-Bana, Yaseen Saleh and Jon Mark Hirshon
Additional contact information
Zeinab Mohammed: Public Health and Community Medicine Department, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
Ahmed Arafa: Public Health and Community Medicine Department, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
Shaimaa Senosy: Public Health and Community Medicine Department, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
El-Morsy Ahmed El-Morsy: Public Health and Community Medicine Department, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
Emad El-Bana: Department of Orthopedic Surgery, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
Yaseen Saleh: College of Medicine, University of Illinois at Chicago, Chicago, IL 60607, USA
Jon Mark Hirshon: Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA

IJERPH, 2020, vol. 18, issue 1, 1-10

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.

Keywords: trauma registries; trauma; medical records; emergency departments; LMICs; Egypt (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2020
References: View references in EconPapers View complete reference list from CitEc
Citations:

Downloads: (external link)
https://www.mdpi.com/1660-4601/18/1/83/pdf (application/pdf)
https://www.mdpi.com/1660-4601/18/1/83/ (text/html)

Related works:
This item may be available elsewhere in EconPapers: Search for items with the same title.

Export reference: BibTeX RIS (EndNote, ProCite, RefMan) HTML/Text

Persistent link: https://EconPapers.repec.org/RePEc:gam:jijerp:v:18:y:2020:i:1:p:83-:d:467718

Access Statistics for this article

IJERPH is currently edited by Ms. Jenna Liu

More articles in IJERPH from MDPI
Bibliographic data for series maintained by MDPI Indexing Manager ().