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The Effect of Using a Checklist on Quality Improvement of History Taking from Trauma Patients

Gholamreza Faridaalaee, Behzad Boushehri, Bahram Ebrahimi
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Abstract

Introduction: To date, no study with a proper sample size has been done to evaluate the efficiency of using pre-designed checklists in history taking of trauma patients in Iran. Therefore, the present study was designed to evaluate the pre-designed checklist’s effects on the quality of history taking in trauma patients referred to the emergency department (ED). Methods: In the present prospective cross-sectional study, data of the trauma patients presented to the ED were recorded either with or without using a checklist, randomly. The designed checklist consisted of personal data, trauma mechanism, wound characteristics and trauma severity, severity and location of injuries, and the patient’s diagnostic and therapeutic plans. The quality of data gathering in each evaluated item was divided into 3 groups of complete recording, incomplete recording, and not recorded. Data recording quality was compared between the 2 groups using chi square or exact Fisher’s test. In all analyses, p < 0.05 was defined as significance level. Results: In the preset study, patient data were gathered without using a checklist in 795 and using a checklist in 384 cases. Complete and accurate data recording in all items was more frequent in the group that had used the checklist (p < 0.001). Recording injury location without using a checklist was complete in only 20.8% of the cases. This rate increased to 95.6% when the checklist was used. In addition, complete and accurate recording of the diagnostic plan increased from 9% to 72.8%, and complete and accurate recording of the therapeutic plan raised from 14% to 68.7%. The improvements in data recording quality was significant in all cases. Conclusion: It seems that using pre-designed checklists for history taking in trauma patients, leads to a significant increase in quality of data recording and history taking.


Keywords

Wounds and injuries; medical history taking; medical errors; checklist

References

Sharifian R, Ghazisaeedi M. Information registration in surgical special sheets for discharege patients in Tehran University of Medical Sciences Teaching Hospitals , 2005. Payavard Salamat. 2008;2(1):31-9.

Quinn C. The medical record as a forensic resource: Jones & Bartlett Learning; 2004.

Gillum RF. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. Am J Med. 2013;126(10):853-7.

Siegler EL. The evolving medical record. Annals of internal medicine. 2010;153(10):671-7.

Camp CL, Smoot RL, Kolettis TN, Groenewald CB, Greenlee SM, Farley DR, editors. Patient records at Mayo Clinic: lessons learned from the first 100 patients in Dr Henry S. Plummer's dossier model. Mayo Clinic Proceedings; 2008: Elsevier.

Weed LL. Knowledge coupling, medical education and patient care. Critical reviews in medical informatics. 1985;1(1):55-79.

Corbett JT. Keeping Records in General Practice. The Journal of the College of General Practitioners. 1962;5(2):270.

Tait I. History of our records. British medical journal (Clinical research ed). 1981;282(6265):702.

Miller AR, Tucker CE. Can health care information technology save babies? J Polit Econ. 2011;119(2):289-324.

Faridaalaee G, Boushehri B, Mohammadi N, Safari O. Evaluating the Quality of Multiple Trauma Patient Records in the Emergency Department of Imam Khomeini Hospital in Urmia. Iranian Journal of Emergency Medicine. 2015;2(1).

Esmailian M, Nasr-Esfahani M. The Quality of Patients’ Files Documentation in Emergency Department; a Cross Sectional Study. Iranian Journal of Emergency Medicine. 2014;1(1):pp. 16-21.

Humphreys T, Shofer FS, Jacobson S, Coutifaris C, Stemhagen A. Preformatted charts improve documentation in the emergency department. Annals of emergency medicine. 1992;21(5):534-40.

O'Connor AE, Finnel L, Reid J. Do preformatted charts improve doctors' documentation in a rural hospital emergency department? A prospective trial. The New Zealand medical journal. 2001;114(1141):443-4.

Wrenn K, Rodewald L, Lumb E, Slovis C. The use of structured, complaint-specific patient encounter forms in the emergency department. Annals of emergency medicine. 1993;22(5):805-12.

Park SL, Parwani AV, Pantanowitz L. Electronic Medical Records. Practical Informatics for Cytopathology: Springer; 2014. p. 121-7.

Shepard J, Hadhazy E, Frederick J, et al. Using electronic medical records to increase the efficiency of catheter-associated urinary tract infection surveillance for National Health and Safety Network reporting. American journal of infection control. 2014;42(3):e33-e6.

Thomas AA, Zheng C, Jung H, et al. Extracting data from electronic medical records: validation of a natural language processing program to assess prostate biopsy results. World journal of urology. 2014;32(1):99-103.

Johnson AJ, Chen MYM, Swan JS, Applegate KE, Littenberg B. Cohort Study of Structured Reporting Compared with Conventional Dictation. Radiology. 2009;253(1):74-80.


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