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Journaldokumentasjon for alvorlig syke
Engelsk titel: Medical records of critically ill patients Läs online Författare: Aronsen T ; Rekkedal LM ; Hole A ; Aadahl P Språk: Nor Antal referenser: 12 Dokumenttyp: Fallbeskrivning UI-nummer: 03091298

Tidskrift

Tidsskrift for Den Norske Laegeforening 2003;123(16)2257-9 ISSN 0029-2001 E-ISSN 0807-7096 KIBs bestånd av denna tidskrift Denna tidskrift är expertgranskad (Peer-Reviewed)

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 For 84 % of the patients, therapy had been withdrawn or withhold; 58 % of these cases were insufficiently documented.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.