A retrospective quality assessment of pre-hospital emergency medical documentation in XXXX in south-eastern Norway.

@entity1 @entity64 @entity772 @entity2641 @entity130
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 @entity64 ( @entity64 ). METHODS: Records from police, Emergency Medical Communication Centers (EMCC), ground and air ambulances were retrospectively collected for 189 @entity64 involving 392 @entity1 . Documentation of Glasgow @entity772 Scale (GCS), respiratory rate (RR), and systolic blood pressure (SBP) was classified as exact values, @entity2641 categories, clinical descriptions enabling post-hoc inference of @entity2641 categories, or missing. The distribution of values of exact versus inferred @entity2641 categories were compared (Chi-square test for trend). RESULTS: 25% of ground and 11% of air ambulance records were unretrieveable. @entity1 name, birth date, and transport destination was documented in >96% of ambulance records and 81% of EMCC reports. Only 54% of @entity1 encounter times were transmitted to the EMCC, but 77% were documented in ground and 96% in air ambulance records. Ground ambulance records documented exact values of GCS in 48% and SBP in 53% of cases, exact RR in 10%, and RR @entity2641 categories in 54%. Clinical descriptions made post-hoc inference of @entity2641 categories possible in another 49% of cases for GCS, 26% for RR, and 20% for SBP. Air ambulance records documented exact values of GCS in 89% and SBP in 84% of cases, exact RR in 7% and RR @entity2641 categories in 80%. Overall, for lower @entity2641 categories of GCS, RR and SBP the proportion of actual documented values to inferred values increased (All: p<0.001). Also, documentation of repeated assessment was more frequent for low @entity2641 categories of GCS, RR, and SBP (All: p<0.001). Mechanism of injury was documented in 80% of cases by ground and 92% of cases by air ambulance. CONCLUSION: EMS documentation of logistic and mechanistic variables was adequate. @entity1 physiology was frequently documented only as descriptive text. Our finding indicates a need for improved procedures, training, and tools for EMS documentation. Documentation is in itself a quality criterion for appropriate care and is crucial to @entity130 research.
