Historia clínica para trauma. Registro hospitalario específico para pacientes traumatizados: Un recurso para países en desarrollo

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

Authors

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.

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