Public Health and Community Medicine Department, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt.
Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Int J Environ Res Public Health. 2020 Dec 24;18(1):83. doi: 10.3390/ijerph18010083.
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.
埃及医院的创伤记录被广泛怀疑不足以开发实用且有用的创伤登记系统，这对于告知初级和二级预防都至关重要。我们审查了埃及上埃及本尼苏夫大学医院存档的创伤患者病历记录，以评估其在四个领域的完整性：人口统计学数据，包括联系方式；管理数据，跟踪患者从入院到出院的情况；临床数据，包括生命体征和格拉斯哥昏迷评分；以及描述创伤性事件原因的数据（损伤机制、受伤时的活动以及地点/环境）。研究中纳入的 539 份病历记录在这四个审查领域存在明显的缺陷。总体而言，74.3%的人口统计学字段、66.5%的管理字段、55.0%的临床字段和只有 19.9%的详细描述创伤性事件原因的字段填写完整。至关重要的是，只有 7.6%、25.8%和 43.6%的记录报告了血氧饱和度、到达时间和联系方式。不到四分之一的记录提供了任何关于创伤原因的详细信息。因此，本尼苏夫大学医院目前基于纸质的医疗记录系统不足以开发实用的创伤登记系统。需要进一步努力，以有效且全面地记录创伤数据，从而为改善患者治疗提供信息。
