Completeness of medical records in emergency trauma care and an IT-based strategy for improvement
Completeness of medical records in emergency trauma care and an IT-based strategy for improvement
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DOI：
10.1080/09670260701231284
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发表时间：
2007-01-01
期刊：
影响因子：
--
通讯作者：
Berg, M.
中科院分区：
文献类型：
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作者：
De Mul, M.;Berg, M.
医疗创伤记录，在事故和紧急部门（AED）产生的医疗专业人员和关心护理质量的各方都非常关注。虽然（纸质）病历是卫生保健专业人员日常工作和第三方质量评估的重要数据来源，但由于不完整，通常会受到负面评价。在本文中，我们将说明完整性与使用记录的目的有关。我们区分了两种使用创伤记录的情况：AED的初级护理过程和创伤护理的评估和监测。在这些情况下，病历的不完整性有不同的价值。特别是关于质量评估的信息需求，更具体地说，国家创伤登记处，AED的工作流程尚未充分发展。信息技术在提高完整性和促进质量评估方面具有巨大的力量，但它本身并不能解决不完整性问题。我们提出的一个解决方案是通过引入一个职员来重组记录过程。这个职员也可以是暂时脱离直接病人护理的护士或医生。
The medical trauma record, produced in the Accident & Emergency Departments (AEDs) receives much attention from both health- care professionals and parties interested in quality of care. While it is an important data source for health- care professionals in their everyday work, and for quality assessment by third parties, the (paper) medical record is usually negatively evaluated because of incompleteness. In this article, we show that completeness is relative to the purpose for which the record is used. We distinguish two contexts in which the trauma record is used: the primary- care process at the AED, and assessment and monitoring of trauma care. Incompleteness of the medical record is valued differently in these contexts. Especially with regard to the information demands of quality assessment, and more specifically the national trauma registry, the work processes in the AED have not evolved sufficiently as yet. Information technology has great power to improve completeness and to facilitate quality assessment, but it cannot solve the problem of incompleteness in itself. One solution we propose is to restructure the recording process by introducing a clerk. This clerk could also be a nurse or physician who is temporarily released from direct patient care.