PMID- 21453536
OWN - NLM
STAT- MEDLINE
DCOM- 20110912
LR  - 20220330
IS  - 1757-7241 (Electronic)
IS  - 1757-7241 (Linking)
VI  - 19
DP  - 2011 Mar 31
TI  - A retrospective quality assessment of pre-hospital emergency medical 
      documentation in motor vehicle accidents in south-eastern Norway.
PG  - 20
LID - 10.1186/1757-7241-19-20 [doi]
AB  - BACKGROUND: Few studies have evaluated pre-hospital documentation quality. We 
      retrospectively assessed emergency medical service (EMS) documentation of key 
      logistic, physiologic, and mechanistic variables in motor vehicle accidents 
      (MVAs). METHODS: Records from police, Emergency Medical Communication Centers 
      (EMCC), ground and air ambulances were retrospectively collected for 189 MVAs 
      involving 392 patients. Documentation of Glasgow Coma Scale (GCS), respiratory 
      rate (RR), and systolic blood pressure (SBP) was classified as exact values, RTS 
      categories, clinical descriptions enabling post-hoc inference of RTS categories, 
      or missing. The distribution of values of exact versus inferred RTS categories 
      were compared (Chi-square test for trend). RESULTS: 25% of ground and 11% of air 
      ambulance records were unretrieveable. Patient name, birth date, and transport 
      destination was documented in >96% of ambulance records and 81% of EMCC reports. 
      Only 54% of patient encounter times were transmitted to the EMCC, but 77% were 
      documented in ground and 96% in air ambulance records. Ground ambulance records 
      documented exact values of GCS in 48% and SBP in 53% of cases, exact RR in 10%, 
      and RR RTS categories in 54%. Clinical descriptions made post-hoc inference of 
      RTS categories possible in another 49% of cases for GCS, 26% for RR, and 20% for 
      SBP. Air ambulance records documented exact values of GCS in 89% and SBP in 84% 
      of cases, exact RR in 7% and RR RTS categories in 80%. Overall, for lower RTS 
      categories of GCS, RR and SBP the proportion of actual documented values to 
      inferred values increased (All: p<0.001). Also, documentation of repeated 
      assessment was more frequent for low RTS categories of GCS, RR, and SBP (All: 
      p<0.001). Mechanism of injury was documented in 80% of cases by ground and 92% of 
      cases by air ambulance. CONCLUSION: EMS documentation of logistic and mechanistic 
      variables was adequate. Patient physiology was frequently documented only as 
      descriptive text. Our finding indicates a need for improved procedures, training, 
      and tools for EMS documentation. Documentation is in itself a quality criterion 
      for appropriate care and is crucial to trauma research.
CI  - (c) 2011 Staff and Sovik; licensee BioMed Central Ltd.
FAU - Staff, Trine
AU  - Staff T
AD  - Department of Research, Norwegian Air Ambulance Foundation, Drobak, Norway. 
      trine.staff@snla.no
FAU - Sovik, Signe
AU  - Sovik S
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20110331
PL  - England
TA  - Scand J Trauma Resusc Emerg Med
JT  - Scandinavian journal of trauma, resuscitation and emergency medicine
JID - 101477511
SB  - IM
MH  - Accidents, Traffic/*statistics & numerical data
MH  - Cross-Sectional Studies
MH  - Documentation/*standards
MH  - Emergency Medical Services/*organization & administration
MH  - Humans
MH  - Norway
MH  - Quality Assurance, Health Care/*methods
MH  - Retrospective Studies
PMC - PMC3080326
EDAT- 2011/04/02 06:00
MHDA- 2011/09/13 06:00
PMCR- 2011/03/31
CRDT- 2011/04/02 06:00
PHST- 2010/10/01 00:00 [received]
PHST- 2011/03/31 00:00 [accepted]
PHST- 2011/04/02 06:00 [entrez]
PHST- 2011/04/02 06:00 [pubmed]
PHST- 2011/09/13 06:00 [medline]
PHST- 2011/03/31 00:00 [pmc-release]
AID - 1757-7241-19-20 [pii]
AID - 10.1186/1757-7241-19-20 [doi]
PST - epublish
SO  - Scand J Trauma Resusc Emerg Med. 2011 Mar 31;19:20. doi: 10.1186/1757-7241-19-20.