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复苏书面语言:满足心脏骤停文档记录的标准。

Resuscitation of the written word: meeting the standard for cardiac arrest documentation.

机构信息

Anaesthetic Department, Leeds General Infirmary.

出版信息

Clin Med (Lond). 2011 Aug;11(4):348-52. doi: 10.7861/clinmedicine.11-4-348.

Abstract

The aim of this study was to audit cardiac arrest documentation within a UK teaching hospital, survey the regional use of proformas for data collection, and consider the need for a standardised national template. A prospective audit comparing cardiac arrest documentation to General Medical Council (GMC) professional standards and the 'Utstein' fields was carried out, along with a survey of regional resuscitation officers for the use of standardised templates. The main outcome measures were the design of 'best practice' template using GMC guidelines and the 'Utstein' fields. An audit of medical notes involving a cardiac arrest call against the template was performed. There was limited documentation concerning process, events and outcome of arrest calls, as well as minimal regional use of standard templates or consensus on the essential content of medical documentation. Documentation of cardiac arrests in the Leeds Teaching Hospitals does not meet the 'Utstein' recommendations to provide enough information for audit of cardiac arrest procedure. The regional survey indicates that this problem is likely to be widespread.

摘要

本研究旨在审核英国一所教学医院的心脏骤停记录,调查区域内使用表格收集数据的情况,并考虑是否需要制定标准化的全国模板。我们进行了一项前瞻性审核,将心脏骤停记录与英国医学总会(GMC)专业标准和“Utstein”标准进行了比较,并对区域复苏官员进行了标准化模板使用情况的调查。主要的观察指标是使用 GMC 指南和“Utstein”标准制定“最佳实践”模板的设计。我们对一份涉及心脏骤停呼叫的医疗记录进行了模板审核。关于心脏骤停呼叫的过程、事件和结果的记录有限,区域内标准模板的使用也很少,对医疗记录的基本内容也没有达成共识。利兹教学医院的心脏骤停记录不符合“Utstein”的建议,没有提供足够的信息来审核心脏骤停程序。区域调查表明,这个问题可能很普遍。

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