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Zur Qualität der Dokumentation der Schockraumversorgung schwer Traumatisierter: ein Vergleich von primär EDV-gestützter und handschriftlicher Dokumentation

Universität Ulm. Medizinische Fakultät
Publication Date
  • Pen <Datentechnik>
  • Traumabegleitbogen
  • Schockraummanagement
  • Shock
  • Traumatic
  • Medizinische Dokumentation
  • Qualitätsmanagement
  • Schockraum
  • Traumaregister


Quality management is a decisive factor in optimizing the treatment of major trauma cases in the emergency room (ER). In this context high quality data recording is of fundamental importance. Regarding data quality, "online" - especially Tablet-PC based - recording techniques are favoured. But up to now, there is no study really proving a higher quality of ER data by use of such a technique in comparison with a paper based technique. In all major trauma cases a standardized ER data recording was performed; the study collective was divided into two subgroups: the "Tablet-PC collective" using a Pen-Computer based technique and the "Paper collective" using a paper based technique. The "total dataset" comprises the core dataset expanded by our hospital-specific dataset. As "core dataset" we defined the dataset which comprises the recommendations for uniform reporting of data following major trauma of the German Society of Traumatology. Data quality was defined as level of data completeness. A total of n = 207 major trauma cases underwent ER management. There was no statistical significant difference between the "Pen collective" (n = 135) and the "Paper collective" (n = 72) regarding gender, age, mechanism of injury, injury severity (ISS 18 vs. 13; p > 0,05) and duration of ER treatment (20.2 vs. 20.4 minutes; p = 0,9). There was no correlation between degree of injury severity and level of dataset completeness. Total dataset completeness was significantly higher within the "Tablet-PC collective" (94,67 % vs. 81,55 %; p < 0.01); the same applies to the "core dataset" completeness: 97.03 % vs. 91.34 %; p < 0.01. Defining data quality as level of data completeness, a Tablet-PC based recording technique seems superior to the conventional paper based technique.

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