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.

Authors and Affiliations