Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt.
Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt.
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DOI：
10.3390/ijerph18010083
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发表时间：
2020-12-24
影响因子：
--
通讯作者：
Hirshon JM
中科院分区：
文献类型：
--
作者：
Mohammed Z;Arafa A;Senosy S;El-Morsy EA;El-Bana E;Saleh Y;Hirshon JM
人们普遍怀疑埃及医院的创伤记录不足以建立一个实用和有用的创伤登记册，而这对提供初级和二级预防信息至关重要。我们回顾了上埃及贝尼苏夫大学医院收治的创伤患者的存档纸质记录，以确保四个领域的完整性：人口统计学数据，包括联系信息，从入院到出院跟踪患者的管理数据，临床数据，包括生命体征和格拉斯哥昏迷量表评分，以及描述因果创伤事件（损伤机制，损伤时的活动和位置/设置）的数据。在研究中纳入的539份病历中，大多数在四个审查领域存在重大缺陷。总体而言，完成了74.3%的人口统计学领域、66.5%的行政领域、55.0%的临床领域和19.9%的详细说明因果事件的领域。关键的是，血氧饱和度、到达时间和联系信息分别仅占记录的7.6%、25.8%和43.6%。不到四分之一的记录提供了有关创伤原因的任何细节。因此，贝尼苏韦夫大学医院目前的纸质病历系统不足以建立一个实用的创伤登记处。需要做出更多努力，开发有效和全面的创伤数据文件，以告知和改善患者护理。
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.
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影响因子：
3.7
作者：
Chichom-Mefire A;Nwanna-Nzewunwa OC;Siysi VV;Feldhaus I;Dicker R;Juillard C
通讯作者：
Juillard C
DOI：
10.1136/injuryprev-2015-041616
发表时间：
2016-02
期刊：
Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention
影响因子：
--
作者：
Haagsma JA;Graetz N;Bolliger I;Naghavi M;Higashi H;Mullany EC;Abera SF;Abraham JP;Adofo K;Alsharif U;Ameh EA;Ammar W;Antonio CA;Barrero LH;Bekele T;Bose D;Brazinova A;Catalá-López F;Dandona L;Dandona R;Dargan PI;De Leo D;Degenhardt L;Derrett S;Dharmaratne SD;Driscoll TR;Duan L;Petrovich Ermakov S;Farzadfar F;Feigin VL;Franklin RC;Gabbe B;Gosselin RA;Hafezi-Nejad N;Hamadeh RR;Hijar M;Hu G;Jayaraman SP;Jiang G;Khader YS;Khan EA;Krishnaswami S;Kulkarni C;Lecky FE;Leung R;Lunevicius R;Lyons RA;Majdan M;Mason-Jones AJ;Matzopoulos R;Meaney PA;Mekonnen W;Miller TR;Mock CN;Norman RE;Orozco R;Polinder S;Pourmalek F;Rahimi-Movaghar V;Refaat A;Rojas-Rueda D;Roy N;Schwebel DC;Shaheen A;Shahraz S;Skirbekk V;Søreide K;Soshnikov S;Stein DJ;Sykes BL;Tabb KM;Temesgen AM;Tenkorang EY;Theadom AM;Tran BX;Vasankari TJ;Vavilala MS;Vlassov VV;Woldeyohannes SM;Yip P;Yonemoto N;Younis MZ;Yu C;Murray CJ;Vos T
通讯作者：
Vos T
DOI：
10.1016/j.ijotn.2017.10.001
发表时间：
2018-02-01
影响因子：
1.4
作者：
Nolan, Heather R.;Ashley, Dennis W.;Christie, D. Benjamin, III
通讯作者：
Christie, D. Benjamin, III
影响因子：
2.6
作者：
Shivasabesan, Gowri;O'Reilly, Gerard M.;Mitra, Biswadev
通讯作者：
Mitra, Biswadev
DOI：
10.1080/09670260701231284
发表时间：
2007-01-01
期刊：
MEDICAL INFORMATICS AND THE INTERNET IN MEDICINE
影响因子：
--
作者：
De Mul, M.;Berg, M.
通讯作者：
Berg, M.