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Development of the emergency room patient record in Theodor Bilharz Research Institute Hospital

Thesis

Last updated: 06 Feb 2023

Subjects

-

Tags

Public Health

Advisors

El-Lawendi, Muna E., El-Ayyatt, Afaf-Hanem A., Zayed, Mushira A.

Authors

Kheyami, Muaz Abdel-Wadoud

Accessioned

2017-07-12 06:41:37

Available

2017-07-12 06:41:37

type

M.Sc. Thesis

Abstract

Emergency room provides immediate care to sustain life or to preventcritical consequences. Emergency room patient record should document theprocess of evaluation, management, medical decision making and dispositionof a patient.The emergency room form design should be standardized toassist in the efficient gathering of data and dissemination of information.The aim of this study was toimprove the quality of clinical care throughdevelopment of the emergency room patient record, depending on medicalrecords and data quality standards and considering health team needs andpatients’ characteristics.The study used an interventional hospital based design;it involvedsituational analysis of the emergency room medical record system,assessment of the provisional emergency room patient record, needsassessment of health team and finally implementation and assessment of thefinal emergency room patient record.The provisional record form applied the standards with absence of fewelements and information gaps were threatening it. Data quality showedalmost the same attitude among physicians and registry clerks withinsufficient conciseness showed by physicians. Patients were mostly elderlypeople with slight dominance of males; nearby areas were the main source ofcases, general condition of most cases was relatively good with highprevalence of liver and GIT cases and one third of the emergency cases wereadmitted.Needs assessment highlighted the need of: more spaces,classification of items, decreasing their number and use of checklistswithpreference to make physicians the responsible for diagnosis coding, training was needed to improve documentation in the emergency room.A trialform was modified according to the health team needs (taking intoconsideration the adherence to national standards and data qualityresults).The final form structure was convenient, the newly added itemsshowed sufficient data quality,while the modified items declared that the subclassificationsas well as checklists showed obvious success.

Issued

1 Jan 2011

DOI

http://dx.doi.org/10.21473/iknito-space/36912

Details

Type

Thesis

Created At

28 Jan 2023