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使用急诊科记录表与住院病历评估急性脊髓损伤严重程度。

Rating AIS severity using emergency department sheets vs. inpatient charts.

作者信息

MacKenzie E J, Shapiro S, Eastham J N

出版信息

J Trauma. 1985 Oct;25(10):984-8. doi: 10.1097/00005373-198510000-00010.

Abstract

To determine whether sufficiently accurate estimates of injury severity can be based on limited data as would be available from an Emergency Department (ED) Sheet, Abbreviated Injury Severity (AIS) scores were derived for 166 trauma patients using two different sources of data--the ED sheet and inpatient medical chart. These severity scores were compared by type of person assigning the scores and by external cause of the injury. Results indicate that in general, the ED sheet is not a suitable alternative to the complete inpatient chart when coding severity for individuals who sustain injuries severe enough to result in hospital admission.

摘要

为了确定能否基于急诊科(ED)表格所提供的有限数据得出足够准确的损伤严重程度估计值,我们使用两种不同的数据来源——ED表格和住院病历,为166名创伤患者得出了简明损伤定级(AIS)评分。这些严重程度评分根据评分人员类型和损伤外部原因进行了比较。结果表明,一般来说,对于受伤严重到需要住院治疗的个体,在对其严重程度进行编码时,ED表格并非完整住院病历的合适替代物。

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