Tài liệu Báo cáo y học: " A retrospective quality assessment of pre-hospital emergency medical documentation

Background: Few studies have evaluated pre-hospital documentation quality. We retrospectively assessed emergency medical service (EMS) documentation of key logistic, physiologic, and mechanistic variables in motor vehicle accidents (MVAs). Methods: Records from police, Emergency Medical Communication Centers (EMCC), ground and air ambulances were retrospectively collected for 189 MVAs involving 392 patients. Documentation of Glasgow Coma Scale (GCS), respiratory rate (RR), and systolic blood pressure (SBP) was classified as exact values, RTS categories, clinical descriptions enabling post-hoc inference of RTS categories, or missing. The distribution of values of exact versus inferred RTS categories were compared (Chi-square test for trend).