Literature DB >> 20442162

Standard operating procedures as a tool to improve medical documentation in preclinical emergency medicine.

Roland C E Francis1, Willi Schmidbauer, Claudia D Spies, Marc Sörensen, Florian Bubser, Thoralf Kerner.   

Abstract

AIM: To evaluate the effect of standard operating procedures (SOPs) to improve the completion of patient care documentation items on patient care reports (PCRs) in a physician-staffed, 4500-calls-per-year preclinical ground emergency medical service (EMS) base.
METHODS: Two series of PCRs were analysed before (n=505) and after (n=520) the introduction of SOPs. PCR forms were analysed for the rate of completion of documentation comparing prompted data in check boxes and non-prompted data written in blank spaces at the discretion of the emergency physician. The chi2 test for independence was used to assess the effect of SOPs and prompting on data completion rate.
RESULTS: SOPs improved the documentation rate of numerous prompted and non-prompted items, independent of whether these items had a high (eg, Glasgow Coma Score: 91.5% vs 95.7%) or a low documentation rate during the pre-SOP period (eg, allergies: 6.2% vs 18.7%). Prompted items were more frequently documented than non-prompted items, both before and after the introduction of SOPs. Lowest rates were found among non-prompted items (eg, 'last meal' 3.6%).
CONCLUSIONS: In this EMS base, developing SOPs is an effective tool to improve the quality of PCRs and the rate of completion of documentation items. Check boxes on PCR forms seem to have an important impact as they prompt the initial assessment, treatment and documentation of the actions taken during an EMS call. Consequently, SOPs and check boxes may serve to improve the transition of important information to emergency department staff, and thus contribute to improved patient care.

Entities:  

Mesh:

Year:  2010        PMID: 20442162     DOI: 10.1136/emj.2008.070284

Source DB:  PubMed          Journal:  Emerg Med J        ISSN: 1472-0205            Impact factor:   2.740


  7 in total

1.  Impact of implementing an EMR on physical exam documentation by ambulance personnel.

Authors:  R Katzer; D J Barton; S Adelman; S Clark; E L Seaman; K B Hudson
Journal:  Appl Clin Inform       Date:  2012-07-25       Impact factor: 2.342

2.  A retrospective quality assessment of pre-hospital emergency medical documentation in motor vehicle accidents in south-eastern Norway.

Authors:  Trine Staff; Signe Søvik
Journal:  Scand J Trauma Resusc Emerg Med       Date:  2011-03-31       Impact factor: 2.953

3.  Effects of a case-based interactive e-learning course on knowledge and attitudes about patient safety: a quasi-experimental study with third-year medical students.

Authors:  Rainer Gaupp; Mirjam Körner; Götz Fabry
Journal:  BMC Med Educ       Date:  2016-07-11       Impact factor: 2.463

4.  Quality of Documentation as a Surrogate Marker for Awareness and Training Effectiveness of PHTLS-Courses. Part of the Prospective Longitudinal Mixed-Methods EPPTC-Trial.

Authors:  David Häske; Stefan K Beckers; Marzellus Hofmann; Rolf Lefering; Bernhard Gliwitzky; Christoph C Wölfl; Paul Grützner; Ulrich Stöckle; Marc Dieroff; Matthias Münzberg
Journal:  PLoS One       Date:  2017-01-20       Impact factor: 3.240

5.  Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway.

Authors:  Kristin Tønsager; Marius Rehn; Kjetil G Ringdal; Hans Morten Lossius; Ilkka Virkkunen; Øyvind Østerås; Jo Røislien; Andreas J Krüger
Journal:  BMC Health Serv Res       Date:  2019-03-08       Impact factor: 2.655

6.  [Quality of documentation and treatment in the non-physician staffed ambulance: a retrospective analysis of emergency protocols from the city of Aachen].

Authors:  Maximilian Klein; Hanna Schröder; Stefan K Beckers; Christina Borgs; Rolf Rossaint; Marc Felzen
Journal:  Anaesthesiologie       Date:  2022-03-22

7.  Standard operating procedure changed pre-hospital critical care anaesthesiologists' behaviour: a quality control study.

Authors:  Leif Rognås; Troels Martin Hansen; Hans Kirkegaard; Else Tønnesen
Journal:  Scand J Trauma Resusc Emerg Med       Date:  2013-12-05       Impact factor: 2.953

  7 in total

北京卡尤迪生物科技股份有限公司 © 2022-2023.