Historia clínica para trauma. Registro hospitalario específico para pacientes traumatizados:

Julio Trostchansky; Gustavo Sánchez; Pablo Dibarboure; Joaquín Bado; Sebastián Castiñeiras; Sebastián Sarutte; Danilo González; Fernando Machado

Julio Trostchansky Universidad de la República, Facultad de Medicina, Hospital Maciel, Cirugía de Tórax. Asistente
Gustavo Sánchez Universidad de la República, Facultad de Medicina, Hospital Maciel, Clínica Quirúrgica 2. Asistente
Pablo Dibarboure Universidad de la República, Facultad de Medicina, Hospital Maciel, Cirugía de Tórax. Residente
Joaquín Bado Universidad de la República, Facultad de Medicina, Hospital Maciel, Clínica Quirúrgica 2. Asistente
Sebastián Castiñeiras Universidad de la República, Facultad de Medicina, Hospital Maciel, Clínica Quirúrgica 2. Estudiante de Medicina
Sebastián Sarutte Universidad de la República, Facultad de Medicina, Hospital Maciel, Clínica Quirúrgica 2. Estudiante de Medicina
Danilo González Universidad de la República, Facultad de Medicina, Hospital Maciel, Clínica Quirúrgica 2. Estudiante de Medicina
Fernando Machado Universidad de la República, Facultad de Medicina, Hospital de Clínicas, Dpto. de Emergencia. Prof. Adj

Keywords: MEDICAL REPORTS., WOUNDS AND INJURIES

Abstract

Introduction: trauma constitutes the first cause of death in the population under 40 years old. Epidemiological vigilance is essential for understanding trauma as a disease, and for this purpose usefulness of records basically depends on the quality of the data collected.
Objective: to design and compare the clinical records of traumatized patients with general clinical records in terms of their quantitative and qualitative effectiveness for the collection of specific data of traumatized patients.
Method: we designed a specific clinical record for traumatized patients. Subsequently through a retrospective analysis, we compared it to the data in a similar number of general clinical records conducted prior to the format change. We collected the data of 86 trauma clinical records between June 22, 2006 and May 21, 2007, and 87 general clinical records that were collected between October 18, 2005 and June 21, 2006. The proportion comparison was used for the statistical analysis. Alpha error was set in 5% (p< 0,05) and we calculated Z for each comparison. (calculated Z).
Conclusions: trauma medical records are clearly better than general clinical records form the quantitative and qualitative point of view for the collection of traumatized patients' data. A low cost intervention enables the analysis of the trauma disease in the so called golden hour.

References

(1) American College of Surgeons. National Trauma Data Bank (NTDB). Disponible en: http://www.facs.org/trauma/ntdb/index.html. Consulta: enero 2006.
(2) Pollock DA, McClain PW. Trauma registries. Current status and future porspects. JAMA 1989; 262(16): 2280-3.
(3) Sánchez G, Valsangiacomo P, Trostchansky J, Machado F. Perfil epidemiológico de traumatizados graves en un hospital de agudos. Rev Méd Urug 2006; 22(3): 179-84.
(4) Barrios Camponovo G. Enfermedad traumática en Uruguay: aspectos epidemiológicos. Rev Méd Urug 1995; 11(3): 87-212.
(5) Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O. Injury Surveillance Guidelines. Geneva: World Health Organization, 2001.
(6) Mock CN, Abantanga F, Cummings P, Koepsell TD. Incidence and outcome of injury in Ghana: a community-based survey. Bull World Health Organ 1999; 77(12): 955-64.
(7) Mullins RJ, Veum-Stone J, Hedges JR, Zimmer-Gembeck M, Mann C, Helfand M. An analysis of Hospital Discharge Index as a trauma database. J Trauma 1995; 39(5): 941-8.
(8) Kobusingye OC, Lett RR. Hospital-based trauma registries in Uganda. J Trauma 2000; 48(3): 498-02.
(9) Schultz CR, Ford HR, Cassidy LD, Shultz BL, Blanc C, King-Schultz LW, et al. Development of a hospital-based trauma registry in Haiti: an approach for improving injury surveillance in developing and resource-poor settings. J Trauma 2007; 63(5): 1143-54.
(10) Williams JM, Furbee PM, Prescott JE, Paulson DJ. The emergency department log as a simple injury-surveillance tool. Ann Emerg Med 1995; 25(5): 686-91.
(11) Mock CN, nii-Amon-Kotei D, Maier RV. Low utilization of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma. J Trauma 1997; 42(3): 504-11.
(12) Smith GS, Barss P. Unintentional injuries in developing countries: the epidemiology of a neglected problem. Epidemiol Rev 1991; 13: 228-66.
(13) Barrios Camponovo G, de los Santos Lezama S. Historia clínica única para la enfermedad traumática. Pac Crit (Uruguay) 1997; 10(1): 5-18.
(14) Mandirola HF. Comparación del modelo de datos de la Historia Clínica orientada al problema versus el modelo de recolección de datos tradicional. Disponible en: http//www.sis.org.ar. Consulta: enero 2006.
(15) Rutledge R, Fakhry S, Baker C, Oller D. Injury severity grading in trauma patients: a simplified technique based upon ICD-9 coding. J Trauma 1993; 35(4): 497-507.
(16) Tepas JJ 3rd, Mollitt DL, Talbert JL, Bryant M. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg 1987; 22(1): 14-8.
(17) Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the trauma score. J Trauma 1989; 29(5): 623-9.
(18) Barrios G. Índices de gravedad en el paciente politraumatizado. In: Juambeltz C, Machado F, Trostchansky J. Trauma: la enfermedad del nuevo milenio. Montevideo: Arena, 2005: 97-104.
(19) Samuel JC, Akinkuotu A, Baloyi P, Villaveces A, Charles A, Lee CN, et al. Hospital-based injury data in Malawi: strategies for data collection and feasibility of trauma scoring tools. Trop Doct 2010; 40(2): 98-9.
(20) Razzak J, Marsh D, Stansfield S. District hospital based injury data-are they an option in a developing country? Inj Prev 2002; 8(4): 345-6.

Trauma clinical record. Specfic hospital record for traumatized patients

A resource for developing countries

Abstract

References

Follow on Twitter