The Effect of Using a Checklist on Quality Improvement of History Taking from Trauma Patients

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