Jafar Anisa J N, Fletcher Rachel J, Lecky Fiona, Redmond Anthony D
1Humanitarian and Conflict Response Institute (HCRI),Ellen Wilkinson Building,University of Manchester,Manchester,United Kingdom.
2UK-Med (UK EMT),Ellen Wilkinson Building,University of Manchester,Manchester,United Kingdom.
Prehosp Disaster Med. 2018 Aug;33(4):441-447. doi: 10.1017/S1049023X18000468. Epub 2018 Jul 2.
IntroductionImproving medical record keeping is a key part of the World Health Organization's (WHO's; Geneva, Switzerland) drive to standardize and evaluate emergency medical team (EMT) response to sudden onset disasters (SODs).ProblemIn response to the WHO initiative, the UK EMT is redeveloping its medical record template in line with the WHO minimum dataset (MDS) for daily reporting. When changing a medical record, it is important to understand how well it functions before it is implemented.
The redeveloped medical record was piloted at a UK EMT deployment course using simulated patients in order to examine ease of use by practitioners, and rates of data capture for key MDS variables.
Some parts of the form were consistently poorly filled in, and the way in which the form was completed suggested that the flow of the form did not align with the recorder's natural thought processes when under pressure.
Piloting of a single-sheet triplicate medical record during an EMT deployment simulation led to significant modifications to improve data capture and function.Jafar AJN, Fletcher RJ, Lecky F, Redmond AD. A pilot of a UK emergency medical team (EMT) medical record during a deployment training course. Prehosp Disaster Med. 2018;33(4):441-447.
引言
改善医疗记录保存是世界卫生组织(WHO;瑞士日内瓦)推动应急医疗队(EMT)对突发灾难(SOD)反应标准化和评估的关键部分。
问题
为响应WHO倡议,英国EMT正在根据WHO每日报告的最小数据集(MDS)重新开发其医疗记录模板。在更改医疗记录时,了解其在实施前的功能状况非常重要。
重新开发的医疗记录在英国EMT部署课程中使用模拟患者进行试点,以检查从业者的易用性以及关键MDS变量的数据捕获率。
表格的某些部分填写情况一直很差,并且表格的填写方式表明,在压力下表格的流程与记录者的自然思维过程不一致。
在EMT部署模拟期间对单页一式三份医疗记录进行试点,导致了重大修改,以改善数据捕获和功能。
贾法尔·AJN、弗莱彻·RJ、莱基·F、雷德蒙德·AD。在部署培训课程期间对英国应急医疗队(EMT)医疗记录进行的试点。院前灾难医学。2018;33(4):441 - 447。