Abstract

Introduction: Medical profile is an important source of data regarding the patient, the illness, the doctor’s performance and leads to adequate diagnosis and treatment. Filling out medical profiles correctly, greatly decreases medical errors and leads to accurate diagnosis and proper treatment of the patients. This study aims to evaluate the quality of the patient records of trauma patients admitted to the emergency department of Emam Khomeini Hospital, Urmia, Iran. Methods: In a cross-sectional study, the medical profiles of trauma patients admitted to the emergency department of Emam Khomeini Hospital, Urmia, Iran in November 2013 were evaluated aiming to determine the quality of filling the profiles. All the patients’ medical profiles were evaluated regarding accurate recording of trauma mechanism; size, site of injuries; vital signs recordings; diagnostic and treatment plan. Based on the Likert scale, the quality of data recording was rated as: not recorded, recorded with high quality, recorded with low quality. The data were statistically analyzed using SPSS 21. Results: In this study, 795 profiles were studied and evaluated (66.7% male). The most accurate data recording belonged to mechanism of trauma (92.5%) and the least accurate data recording belonged to diagnostic plan (9%). The highest frequency of incomplete data belonged to the site of injuries caused by trauma (71.7%), the number of injuries (34%) and anatomical depth and severity of trauma (34%). Most cases of missing data belonged to diagnostic plan (91%). In 142 (17.8%) profiles only 1, in 241 (30.3%) profiles 2, and in 277 (34.8%) profiles 3 categories were incomplete and data recording in 135 (16.9%) profiles were incomplete in all categories. In total, 82% of the profiles had 1 or more incomplete categories. Conclusion: Based on the results of this study, the quality of data recordings of trauma patients admitted to the studied emergency department was not satisfying. The highest rate of incomplete data belonged to the site of injury caused by trauma and the highest rate of missing data belonged to diagnostic plan.

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