Smith Erin, Boyle Mal, MacPherson James
Centre for Ambulance and Paramedic Studies, Monash University, Peninsula Campus, McMahons Rd, Frankston VIC 3199, Australia.
Health Inf Manag. 2004;33(4):112-20. doi: 10.1177/183335830403300403.
A retrospective cohort study of the 2002 Victorian prehospital emergency care documentation completed by ambulance paramedics had the objectives: (i) to design and implement a quality assessment tool to determine the quality of the ambulance patient care record (PCR)information; and (ii) to identify critical demographic and clinical items on the ambulance PCR that needed improvement. The study outcomes included a functioning quality assessment tool and associated user guide for prehospital use, and the identification of three critical PCR components requiring improvement. Ninety percent of PCRs passed the quality assessment; 10% (approximately 5 300) contained measurably poor or incomplete documentation.
一项针对2002年维多利亚州救护车医护人员完成的院前急救护理文档进行的回顾性队列研究,其目标如下:(i) 设计并实施一种质量评估工具,以确定救护车患者护理记录(PCR)信息的质量;(ii) 识别救护车PCR上需要改进的关键人口统计学和临床项目。研究结果包括一个可用于院前的有效质量评估工具及相关用户指南,以及识别出三个需要改进的关键PCR组件。90%的PCR通过了质量评估;10%(约5300份)包含明显较差或不完整的文档记录。