Prospective and retrospective evaluation of the traumatic primary medical reports at Suez Canal university hospital

ABSTRACT

The primary medical report is a valuable tool for retrieving any information concerning the patient's medical condition. This study was conducted to evaluate the form and contents of the primary medical reports for traumatic cases at the Emergency Department at Suez Canal University Hospital. This is a descriptive comparative study in which 212 reports were included, divided into 2 groups prospective group [A] and retrospective group [B] and were evaluated according to administrative data, ethical data, medical data, wound description, and medico legal data. The results recorded that there is a significant decrease [P<0.05] in reporting the name of the report's recipient with a clear signature, and in reporting the presence of other injuries and the probability of complications in group A, while vital signs, investigations and management were not recorded in both groups. Dimensions of wounds were significantly decreased [P<0.05] in group A, while the precise description of the site was significantly increased [P<0.05] in the same group. Edges and vital reactions were not recorded in both groups. The type and age of wounds and comment on clothes were not reported in both groups. The duration of healing was significantly decreased [P<0.05] in group A but it was reported correctly. The study demonstrates the lack of accurate issuing of the primary medical reports for traumatic cases at Suez Canal University Hospital. The study has provided a recommended form of the primary medical report designed by the researcher, diagrams demonstrating anatomical body regions in Arabic language and Arabic translation of some important terms used in traumatic medical reports