Lorsbach M, Gillessen A, Revering K, Juhra C
Stabsstelle für Telemedizin, Universitätsklinikum Münster, Hüfferstraße 73-79, 48149, Münster, Deutschland.
Klinik für Innere Medizin, Herz-Jesu-Krankenhaus Hiltrup GmbH, Münster-Hiltrup, Deutschland.
Med Klin Intensivmed Notfmed. 2021 May;116(4):345-352. doi: 10.1007/s00063-020-00661-8. Epub 2020 Feb 10.
The introduction of an electronic health record (EHR) or an emergency care data set (ECDS), as well as reforms in emergency medical care, is currently part of political debate in Germany. Currently, no data are available of how emergency departments could benefit from an ePA or NFD in Germany. The aim of this study was to determine if a patient's medical history has an influence on diagnostic and therapeutic decisions in the emergency department.
To answer this question, a descriptive observational study was conducted in an interdisciplinary emergency department with a study population of n = 96.
For 55 patients (59%) neither a doctor's letter nor a drug list was found. However, in 48% of the patients who were admitted to the hospital via the emergency department, additions to the anamnesis record could be identified. Eight (9%) patients showed that therapy and/or diagnostic decisions should have been discussed or changed if the supplemented anamnestic information had been available in the emergency room. In addition, the study revealed that the duration of the anamnesis was prolonged in case of missing medical history (mean: 10-15 min, standard deviation: ±<5 min). In contrast to the patients with a medical history (mean: 5-10 min, standard deviation: ±<5 min).
Based on the data stored in EHR and ECDS, therapy and diagnostic decisions could be made more reliably. In the absence of a medical history, the time required for medical history taking in emergency departments is significantly longer, which could be reduced by introducing EHR or ECDS.
引入电子健康记录（EHR）或急救护理数据集（ECDS）以及急救医疗改革，目前是德国政治辩论的一部分。目前，尚无关于德国急诊科如何从电子处方（ePA）或国家药品名录（NFD）中受益的数据。本研究的目的是确定患者的病史是否会对急诊科的诊断和治疗决策产生影响。
为回答这个问题，在一个跨学科急诊科进行了一项描述性观察性研究，研究人群为n = 96。
55名患者（59%）既未找到医生信件也未找到药物清单。然而，在通过急诊科入院的患者中，48%的患者可以确定其病史记录有补充信息。8名（9%）患者表明，如果急诊室有补充的病史信息，治疗和/或诊断决策本应进行讨论或改变。此外，研究表明，在病史缺失的情况下，病史采集时间会延长（平均：10 - 15分钟，标准差：±<5分钟）。相比之下，有病史的患者（平均：5 - 10分钟，标准差：±<5分钟）。
基于存储在EHR和ECDS中的数据，可以更可靠地做出治疗和诊断决策。在没有病史的情况下，急诊科采集病史所需时间明显更长，引入EHR或ECDS可以减少这一时间。
