|Year : 2013 | Volume
| Issue : 1 | Page : 11-15
Developing health information documentation in disaster
Nahid Tavakoli1, Maryam Jahanbakhsh2, Maryam Fooladvand3
1 Health Management and Economics Research Center, Isfahan, Iran
2 Management and Health Information Technology, Isfahan University of Medical sciences, Isfahan, Iran
3 Health and Medical Sciences, Research Institute of Shakhespajouh, Isfahan, Iran
|Date of Web Publication||30-Nov-2013|
Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan
Source of Support: This article was extracted from a research No.285021 granted by Isfahan University of Medical Sciences, Conflict of Interest: Study concept and design: Nahid Tavakoli, Maryam Jahanbakhsh, Analysis and interpretation of data: Nahid Tavakoli, Maryam Jahanbakhsh, Drafting of the manuscript: Nahid Tavakoli, Maryam Jahanbakhsh
Introduction: Disaster occurs almost daily in the world and increases the issue of it because of high volume of population, industrialization, and acts of terrorism; my country is one of the most unexpected event areas of the world. Healthcare systems encounter special challenges in disaster management, that they include triage and treatment a large number victims and also victims' information management. To ensure correct way of documentation of victims as introduction information management and effective triage and treatment, useful medical record are necessary, because medical record usually used for patients are too complicated and ineffective to use in case of emergency. Objectives: The objective of this research is design the disaster-victim medical record to document and triage easily for victims in disaster. Materials and Methods: This research is an applied study and has been performed as descriptive study. Source of information is libraries and accepted articles in indexed journals. During survey of corresponding organizations about disaster in Isfahan and absence of a medical record for documentation of victims, researchers identified the organizations of disaster in the world and then gathered necessary data elements for medical record in disaster. Then necessary parameters for the medical record extracted from American and European models. Results: According to situation and standards of Iran, a proper and final pattern designed with assisting management and medical emergencies center in Isfahan province. Discussion: Medical record in disaster relief operations must be simple and useful; medical record used in hospitals is not effective. The proposed model is simple and proper form for documentation of victims and easy reference for accessing clinical, administrative, and statistics information in disaster.
Keywords: Disaster, documentation, medical record, triage
|How to cite this article:|
Tavakoli N, Jahanbakhsh M, Fooladvand M. Developing health information documentation in disaster. Int J Health Syst Disaster Manage 2013;1:11-5
|How to cite this URL:|
Tavakoli N, Jahanbakhsh M, Fooladvand M. Developing health information documentation in disaster. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2020 Jun 1];1:11-5. Available from: http://www.ijhsdm.org/text.asp?2013/1/1/11/122426
| Introduction|| |
Disaster is now occurring daily and has become more prevalent because of increasing global population, industrialization, and acts of terrorism. However, one of the permanent challenges of disaster is victims' information management.  An accident or disaster causing a great number of injured or acute patients produces a variety of different problems. They have to be solved within a short period of time. Special models have been developed in order to save lives.
Attention has to be paid to the following:
- Sort on the spot and ascertain the urgency of treatment and transport
- Make emergency treatment/operations at the damage area
- Organize master mass transport requirements
- Manage an optimal distribution of patients to different hospitals
- Register and handle these patients 
Effective disaster preparedness needs real time collection of medical data and statistical analysis and it helps to create needs assessments during disasters. Obtaining complete medical data from victims has resulted utilization of resources such as ambulances, emergency departments, and care management of victims in disasters. Capturing data on victims of a disaster during the disaster would be ideal, allowing for more victim data to be studied as well as for more accurate data to be collected.  The need to further disaster preparedness has resulted in a call for more comprehensive disaster research. Past disaster research has, for the most part, been limited by the inability to obtain complete medical data from victims of disasters. A national disaster victim database (NDVD) can be developed that will facilitate collection and aggregation of disaster victim medical data from healthcare facilities. Three aspects of the NDVD are discussed: Data requirements: Medical records of disaster victims must be standardized before being uploaded from various databases into the NDVD. Existing data dictionaries provide formats in which data elements can become standardized. Once standardized, data sets from different facilities can be pooled and subjected to analyses. Database System: The three tiers of the NDVD system are: (1) Medical data are collected at the point of care, (2) medical data are entered into databases and converted into a specific format, and 3) formatted data sets are uploaded to the NDVD. 
In the Information and Communication Management Project in Iran, rapid and careful gathering of information and news in disaster management assists with on-time response in the disaster management process. With the proposed software it will be possible to store the victim's information accompanied by their pictures. 
The objective of this research is design the disaster victim medical record to document and triage easily for victims in disaster.
| Materials and Methods|| |
It was a descriptive/practical study in which journal articles and libraries' databases in the field of disaster management were reviewed via internet. The experiences of different countries were studied to design the proposed method. Then, after holding numerous sessions with management and medical emergencies center in Isfahan province, a proper and final pattern was offered for using in disasters according to situation experienced in the country.
| Results|| |
The Hospital Emergency Incident Command System in the United States consists of a chart which has been successfully used as a device to track the location of a disaster patient throughout a facility. It goes without saying that the ability to locate a patient within a hospital following a mass casualty event is a priority.
The Multi Casualty Incident Patient Chart was developed and refined by hospitals in Orange County, California. It is primarily viewed as a patient care record. The record consists of three layers printed on no carbon required (NCR) paper. Pages one and two are quarter sheets which overlay each other so that specific recorded information is transferred from the first page to the second and third (last) pages. The third page of the chart is printed on card stock paper which is durable and adds to the rigidity of the form. This last page is a full 8.5 inches by 11 inches and is glued into a manila file folder.
In the bottom right hand corner of the third sheet (card stock) is a space for a small pad of Post-It Note® -type slips of paper called "flow tags". These flow tags measure 2.5 inches by 2.5 inches square and are preprinted with a space for the disaster victim number, a line to write a hospital department, and a line for a time recording entry. A pad of 10-12 flow tags is pasted onto the lower right hand corner of the last page of the patient chart. The tag is an integral part of this patient tracking system. It is the removal, completion, and depositing of these small paper slips which make this an effective, yet simple patient tracking system. 
In Austria a special model called first aid organization was developed and is described by the system First Aid Station (FAS) (at the damage area in the case of mass accidents).
The Swiss Rescue Association issued guidelines in 1988. In June of 1990 the Casualty Handling System (CHSTM) had been introduced into Austria and has been used since then as a standard in the whole country. The introduction of the CHSTM had been designated as an important contribution to improve medical assistance in case of disasters and major accidents. As per today, the CHSTM has now also been introduced in Slovenia and in some parts of Germany.
The main goals for the use of the CHSTM are:
Firstly; to support an organized way to sort, treat, transport, and hospitalize patients in the case of a disaster. Secondly; to register the patient in a simple and easy way and to deliver the most important information at the earliest possible time about the immediate medical and organizational data, measures such as medical treatment.
However, formal and administrative requirements must not delay rescue, treatment, or transport.
The CHSTM consists of a white water-resistant patient pouch. It is printed orange and black and consists of nonpolluting plastic with an elastic band, which can be attached to the patient. The backside has a cover with a transparent window.
This cover contains: A treatment record (blue), an identification record (pink), five yellow reflecting and self-adhesive triangles with black frame to mark contaminated persons and property, and 30 self-adhesive labels with numbers. 
After studying the processes used in different countries, and surveying the process of documenting injured people's information in the place of disaster, the researcher designed a recommended model of medical records to be used in disasters. After holding numerous sessions with management and medical emergencies center in Isfahan province, a proper and final pattern for using in disasters proposed according to situations experienced in the country.
In this part the two frames of this pattern are discussed:
- The essential information about how to use the injured people's medical record in the disasters.
- The medical record material
The medical record should be made of manila, which is like cardboard. It should be water resistant or a plastic cover should be used to avoid damage from water and blood spots.
- The medical record size
The medical record has been designed to be 15*23 cm in size.
- The tracing labels
The triangles placed in the model are the tracing labels of injured people, which must connect the patient's information with the dossier contents even if the patient is unidentified. There are some preprinted unit numbers in each tracing label that are allocated for every patient. One of these labels is separable so that it can be separated from the dossier and put away in a sack containing the patient's gear and tools.
- Install the medical record
In the surface of the card there is a preprepared hole for attaching a ribbon that can be hung around the patient's neck.
Before a disaster, occurs the triage team and the statisticians are fully trained to complete this card. The dossiers are accessible for the triage team working in the disaster area, and are routinely used for every injured person.
- The instruction to complete the medical record for rescuers and therapists This medical record has been designed as a double-sided side form:
- The front side is completed in the disaster area and at the point of triage by the rescuers and therapists.
This medical record is designed to document the injured people's information in the disaster area. Because the patient is transferred to a medical area center after triage, this form is a device that connects the relationship between the patient, the triage area, and other recovery units. Thus, the injured treatment process is done faster and well. "The completion of this record must in no way delay the patient transport".
There is a small rectangle for recording the rescuer/therapist reach time/date to the injured person's bedside. Also the disaster location or the place that the rescuers have found the injured person is mentioned in this section.
In the second field, the type of injury that is classified in the right table is checked immediately after diagnosing the injured by rescuer/therapist, and the injury local is indicated in the given image in the form.
The third field is related to the injured persons, the vital signs should be completed according to special numbers by the rescuer/therapist in the disaster area.
In the fourth field the number of injured, Glasgow Coma Scale (GCS) is filled and the level of consciousness is checked in the related squares.
The fifth field relates to a capillary return that is divided in two categories (before and after 2 s) and the proper part is checked.
The sixth field relates to the medical and medications procedures. It is placed as a blank space. The procedures and the drugs ordered by rescuer/therapist are recorded in this part.
The last field relates to the priority of the injured person under surveillance, and has four colors. The black color represents dead or severely injured people.
The red color represents those who require the therapeutic procedures in the triage place that should be done rapidly and should be transferred as an absolute priority. The yellow color represents those who require therapeutic procedures in the coming hours. The green color represents those who can wait a few days to have administered. These squares should be check-marked by the rescuer/therapist in the relevant place.
At the bottom of the form, the rescuer/therapist's name and signature must be put legibly.
The statistician completes (B-2), the backside of the form after the victims have been evacuated from the triage site. The aim of designing the backside of the form in advance is to identify the injured, and then to get statistical information and an aid to epidemiologic studies of disaster. "The completion of this record must in no way delay the patient transport."
It should be completed after transferring the victims from the triage area. Even if it has not being completed since the patient was hospitalized in a medical center or hospital, every statistician or subsequent supervisor should complete it. In the first cadre, the date and time of the patient's evacuation should be filled in.
The first medical center that the injured person is settled in is known as the place of transfer.
The second field that is more significant than others includes the injured person's identification data. These data are completed if the statistician could distinguish the injured, and has access to his personal identity. Otherwise the appearance features such as approximate height, hair color, and eye color are recorded. This means that unidentifiable (unknown identity) patients will have a medical record as well.
The last field of the back side is completed for statistical studying of external causes of injuries in disasters, preventive planning, and equipping facilities to prepare for subsequent disasters.
This medical record remains with the injured until he is taken to a medical center or hospital, and to be hospitalized. Then a normal medical record is created in that hospital for the injured and his disaster record is appended to his hospital credentials and remains as part of that dossier forever. In the final period of the treatment, and when the injured person is discharge from the hospital, health information managers codify these causes via International Classification of Diseases books for standardizing data and make a framework to identify the damages from the disasters.
| Discussion|| |
Having complete research about the disasters, results in services being better equipped to respond disasters. Hospitals may not come across patients that have been triaged nor have any information from outside of the hospital. On the other hand there is no standard system to collect data on people injured in disasters in Iran. Since in every occurrence of disaster there is mass of medical problems that we do not have any centralized system to classify, then accumulating all of the data about the disaster in an accurate pattern is a hard task. 
Attempts are often made at collecting data after disasters occur. However, these attempts are sometimes made a year after the event, and often exclude more than 60% of the disaster victims. Furthermore, victims who are contacted many months after the event may not accurately recall their experiences. 
Another problem that statisticians have in disaster epidemiological is the lack of standard data definition systems. Since so many different types of medical problems surround each disaster, and since there is no uniform system of coding the data related to them, it can be difficult to pool disaster data together in a useful manner. One of the other problems of gathering the data is tracing the injured people after the disasters have happened. For the reason that the injured people do not refer to the camps that the red crescent of the USA has provided, and living in these camps requires with registration of the injuries. In addition to this, there is not any centralized database in the camp or hospitals to share the data with other organizations. All of these factors establish challenges for tracing the injured people; however, tracing the injured people is significant for two reasons.
The first significance of the tracing of injured people is to provide the follow-up availability, especially to those who have transferred from a healthcare organization or a camp to another place. The second reason is that the sole way to collect full statistical data of the disaster is tracing the injured people. Tracing the injuries results in to promote the sustain presence. And gathering all the data focuses on promoting the disasters epidemiology. 
In disaster management, procedures such as timing the special services, admission, discharge, transfer protocol, and the injured people's medical records management should be defined. Programming of the specific procedures in dangerous traumas should be taken into consideration. It is also important to record procedures such as exploration and rescue operations in buildings, as soon as the first quake and next quakes occur, and evacuating for foundational reasons and other risks or evacuation for the reason of people mass. 
In disaster management, the evidence that could document the patient's management system seems to be necessary. To document this, the researchers studied the patterns related to the other countries and designed a medical record to keep necessary data in it and to get necessary data in the minimum possible time, when rescuing injured people. The process of documentation, triage and transferring injured people in disasters; is a new matter in disaster management in Iran. By applying a simple medical record to document the process of triage, and transferring the patient, we can provide a comprehensive medical record, which can be utilized in future research. This model includes other information as well. In an attempt to the diagnostic and medical procedures used in the Bam earthquake, research was carried out in some of the Tehran hospitals, 563 injured were diagnosed. Personal interviews with 205 injured people revealed that 81% of them had received any medical procedures in the first place of settlement. This meant that the medical procedures among the injured people accomplished with no delay.  Failure to create records during triage can result in subsequent incorrect information being recalled by patients or healthcare delivers. After triage when the patient is settled in the first keeping place, it is necessary to form a complete medical record even if the patient unidentified. In the next stage of gathering and classification of the data, its delivery and explanation must be carried out at a proper time and to a sufficient standard of quality and an exact report is sent to the centers responsible for the statistical disaster management. During the research, different models were studied; the then researcher designed the model and evaluated a needs assessment appropriate to disaster management in Iran. The final medical record was designed based on comparisons with dossiers from other countries during research.
The medical records considered had some limitations as follows:
In some surveyed countries, it is a long time that many activities have been done about disaster management and documentation of the patient's information even in disasters; either manually or electronically has been acculturated and following that in the moment of disaster, a comprehensive dossier is being used for the injured.
However, in Iran researching disaster management is a new matter and there has been no interest in information management. Hence, with regard to this condition, a simple database should be used which can be gradually improved over time.
The mentioned dossier's three data categorization includes: Clinical, outcome, and identification data.
- The clinical data on the front side of the form consists of several dimensions namely, the type of injury in eight main elements: Concussion, burning, damage from explosion, fracture, open wound, spine damages, crushing, rupture, and other classified cases. That the rescuer/therapist records the injured status with a body schematic aid in front of it.
Also the vital signs, GCS, consciousness level, and the injured capillary return are differentiated and are recorded in separated places in the form. Eventually, the medication and medical procedures for the injured are written in the appropriate places.
- Outcome data of the mentioned damages in the paragraph A, and also injured GCS are the outcome data under consideration, because they are considered as health risks in the future. If these data fields are not completed the next stage after attentive triage, the damages incurred by the injured may not be taken for granted and might cause problems in the long term.
- The injured identification data is the next priority, and is written on the back of the form; it is collected by the statistician after triage and after the injured person has been transferred from the disaster site.
This requires a statistician position to be defined in triage and disaster team. A graduate of the medical records field is the best choice to be taken for this responsibility.
| Acknowledgement|| |
We would like to thank the director of Isfahan's Emergency and Disaster Centre for making available some useful information in this area. Also the authors would like to thank the Isfahan University of Medical Sciences for funding and supporting this research.
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