Engelsk titel: Medical records of critically ill patients
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Författare:
Aronsen T
;
Rekkedal LM
;
Hole A
;
Aadahl P
Email: petter.aadahl@medisin.ntnu.no
Språk: Nor
Antal referenser: 12
Dokumenttyp:
Fallbeskrivning
UI-nummer: 03091298
Sammanfattning
BACKGROUND : Comprehensive, high-quality medical records are necessary for the communication between health care professionals. We wanted to assess the quality of records on critically ill patients in a teaching hospital in relation to statutory requirements and official guidelines.
MATERIAL AND METHODS : We assessed the medical records on 119 patients who died in the hospital upon discharge from its intensive care unit over the 1999 to March 2002 period: the frequency of entries, entries about withdrawal or withholding of therapy, and the quality of the documentation.
RESULTS AND INTERPRETATION : The records were of variable and frequently unacceptable quality. We found several violations of statutory requirements; in several wards this was standard practice. The records of four patients were missing. For 84 % of the patients, therapy had been withdrawn or withhold; 58 % of these cases were insufficiently documented. Eighteen patients had only one entry in their record; seven patients had none, in spite of the fact that they had had long stays in hospital. We find this lack of documentation disturbing, as this is a group of patients in whom even small fluctuations in medical status may have serious effects.