Tan Eric W, Ting Beverlie L, Jia Xiaofeng, Skolasky Richard L, McFarland Edward G
Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
Am J Med Qual. 2013 Jan-Feb;28(1):60-8. doi: 10.1177/1062860612447856. Epub 2012 Jul 13.
The need for accuracy in neurovascular examinations of the extremities of trauma patients is well recognized. The goals of this study were to (a) evaluate the completeness of orthopedic house staff documentation of the neurovascular status of adult patients with extremity trauma, (b) identify the frequency of individual element documentation, and (c) determine if completeness was related to experience. The trauma center's database was reviewed for patients with extremity injuries (June 2006 through January 2008). For 114 patients, the authors assessed the neurovascular examination documentation for completeness (sensory, motor function, and vascular elements) and "perfection" (complete bilateral elements), identified the frequency of individual element documentation, and determined the relationship of completeness to experience (Pearson correlation coefficients; significance, P ≤ .05). There was no complete (all elements) or perfect (complete bilateral) documentation. The element most often documented completely was the sensory examination. Increased examiner experience was significantly associated with decreased sensory and vascular documentation.
创伤患者四肢神经血管检查准确性的必要性已得到广泛认可。本研究的目的是：(a) 评估骨科住院医师对成年肢体创伤患者神经血管状况记录的完整性；(b) 确定各单项记录的频率；(c) 确定完整性是否与经验有关。回顾了创伤中心数据库中2006年6月至2008年1月期间的肢体损伤患者。作者对114例患者的神经血管检查记录进行了完整性（感觉、运动功能和血管要素）和“完美性”（双侧完整要素）评估，确定了各单项记录的频率，并确定了完整性与经验的关系（Pearson相关系数；显著性，P≤0.05）。没有完整（所有要素）或完美（双侧完整）的记录。最常被完整记录的要素是感觉检查。检查者经验的增加与感觉和血管记录的减少显著相关。
