A COMPARISON OF PAPER DOCUMENTATION TO ELECTRONIC DOCUMENTATION FOR TRAUMA RESUSCITATIONS AT A LEVEL I PEDIATRIC TRAUMA CENTER
A COMPARISON OF PAPER DOCUMENTATION TO ELECTRONIC DOCUMENTATION FOR TRAUMA RESUSCITATIONS AT A LEVEL I PEDIATRIC TRAUMA CENTER
复制标题
DOI：
10.1016/j.jen.2014.04.010
复制
发表时间：
2015-01-01
影响因子：
1.7
通讯作者：
Covert, Julia
中科院分区：
文献类型：
--
作者：
Coffey, Carla;Wurster, Lee Ann;Covert, Julia
导言：虽然电子病历减少了错误，提高了患者的安全，但大多数急诊科继续使用纸质文件进行创伤复苏。本研究的目的是比较创伤复苏纸质文件和电子文件的完整性。方法：以2012年8月实现100%电子文件的一级儿科创伤中心为背景。结果：电子文件更多地获取了5个数据元素：团队启动时间(100%比85%，P<；.00)，初步评估(94%比88%，P<；0.036)，主治医生到达时间(98%比93.5%，P<；.036)；.026)、急诊科静脉输液量(94%比88%，P<；.036)和处置(100%比89.5%，P<；.00)。纸质文献更多地记录了一个数据元素：到达之前注射的静脉输液量(92.5%比100%，P<；.00)。在生命体征、急救医护人员的救治、到达急诊科的时间、创伤警报激活水平等5个数据元素上的文档率没有统计学差异。由于电子病历提高了患者的安全性，应将其作为所有创伤复苏的标准记录方法。
Introduction: Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations.Methods: The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n = 200) was compared with a random sample of trauma resuscitations documented electronically (n = 200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation.Results: The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P < .00), primary assessment (94% vs 88%, P < .036), arrival time of attending physician (98% vs 93.5%, P < .026), intravenous fluid volume in the emergency department (94% vs 88%, P < .036), and disposition (100% vs 89.5%, P < .00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P < .00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation.Discussion: Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations.