医疗急救服务中的数据质量评估：一种客观方法。
Data quality assessment in emergency medical services: an objective approach.
机构信息
Department of Health Information Management, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran.
Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, 1996713883, Iran.
出版信息
BMC Emerg Med. 2023 Jan 30;23(1):10. doi: 10.1186/s12873-023-00781-2.
BACKGROUND
In emergency medical services, high quality data are of great importance for patient care. Due to the unique nature of this type of services, the purpose of this study was to assess data quality in emergency medical services using an objective approach.
METHODS
This was a retrospective quantitative study conducted in 2019. The research sample included the emergency medical records of patients who referred to three emergency departments by the pre-hospital emergency care services (n = 384). Initially a checklist was designed based on the data elements of the triage form, pre-hospital emergency care form, and emergency medical records. Then, data completeness, accuracy and timeliness were assessed.
RESULTS
Data completeness in the triage form, pre-hospital emergency care form, and emergency medical records was 52.3%, 70% and 57.3%, respectively. Regarding data accuracy, most of the data elements were consistent. Measuring data timeliness showed that in some cases, paper-based ordering and computer-based data entry was not sequential.
CONCLUSION
Data quality in emergency medical services was not satisfactory and there were some weaknesses in the documentation processes. The results of this study can inform the clinical and administrative staff to pay more attentions to these weaknesses and plan for data quality improvement.
背景
在急救医疗服务中，高质量的数据对于患者护理至关重要。由于这种服务类型的独特性质，本研究旨在采用客观方法评估急救医疗服务中的数据质量。
方法
这是一项 2019 年进行的回顾性定量研究。研究样本包括通过院前急救服务转至三个急救部门的患者的急救病历（n=384）。最初，根据分诊表、院前急救表和急救病历的数据元素设计了一份检查表。然后，评估了数据的完整性、准确性和及时性。
结果
分诊表、院前急救表和急救病历的数据完整性分别为 52.3%、70%和 57.3%。关于数据准确性，大多数数据元素是一致的。衡量数据及时性表明，在某些情况下，纸质医嘱和计算机数据录入并不是连续的。
结论
急救医疗服务中的数据质量不尽如人意，在文档记录过程中存在一些薄弱环节。本研究的结果可以为临床和行政人员提供信息，使他们更加关注这些薄弱环节，并计划进行数据质量改进。
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