New Medical Record Improves the Data of Trauma Patient Care

Abstract

Introduction : Presently many hospitals are pursuing hospital accreditation. One important issue is the improvement of medical recording. Accurate medical recording is very important in order to provide quality patient follow-up, medical education and legal evidence. Because of limitation of time in trauma patient care, important patient data from previous medical record is sometimes missed or not available. The development of a well-organized medical recording system may help to improve accuracy in data recording.
Objective of the study : To compare the new medical record form with the previous one using the hospital accreditation scoring system for medical records.
Methodology : After collecting both new and previous records that were filled-in by the same group of physicians and sixth year medical students in the Trauma Services Unit of Siriraj Hospital from December 1st - 31st 2001, these 30 records in each recording system were randomly placed into the study. Scoring and comparison of the records were performed by staff of the Division of Trauma Surgery, Department of Surgery.
Results : Six parts of the record were compared (patient profile, patient history, physical examination, diagnosis, laboratory and management). By using student's t-test, the new record showed more statistically significant improvement of data recording than the old record in four areas, i.e. patient history, physical examination, diagnosis and management. The laboratory record section could not be compared because different patients needed different investigations. Both new and previous records were recorded completely in the patient profile section.
Conclusion : The new medical recording system will improve recording and therefore improve the care given to injured patients.