Sanghavi Rekha, Shefler Alison
John Radcliffe Hospital, Oxford OX3 9DU, UK.
Resuscitation. 2002 Nov;55(2):167-70. doi: 10.1016/s0300-9572(02)00202-2.
To examine the quality and comprehensiveness of documentation in Paediatric 'cardiac arrests'.
Retrospective chart review.
Tertiary care hospital wards, Paediatric Intensive Care and Accident and Emergency department.
41 children experiencing acute life-threatening events in hospital.
Overall documentation of details related to time, place and personnel was highly variable but generally present in over half of the cases reviewed. Data relating to specific drug-related and interventional therapies was insufficient, as was documentation of time intervals and consequent therapeutic decisions.
Documentation of critical resuscitation episodes in children is below recognised standards and this has potential quality of care and medicolegal implications. Current teaching needs to emphasise this essential aspect of clinical care from the earliest level of training.
检查儿科“心脏骤停”记录的质量和完整性。
回顾性病历审查。
三级护理医院病房、儿科重症监护室和急诊科。
41名在医院发生急性危及生命事件的儿童。
与时间、地点和人员相关的详细信息的总体记录差异很大，但在超过半数的审查病例中通常都有记录。与特定药物相关和介入治疗的数据不足，时间间隔和相应治疗决策的记录也不足。
儿童关键复苏事件的记录低于公认标准，这对护理质量和法医学有潜在影响。当前的教学需要从最早的培训阶段就强调临床护理的这一重要方面。
