Skematisk hoftefrakturjournal og dokumentation af patient- og behandlingsoplysninger. Et kvalitetsudviklingsprojekt
Sammanfattning
Introduction: Conventional medical records suffer from inconsistent and lacking data. In order to improve data concerning the admission and operation after hip fracture, a specially designed hip fracture form was constructed. Materials and methods: The pre-printed form consisted of three data sheets and one sheet for individual notes. All hip fracture patients admitted in two periods before and after introduction of the form were included in the study: 273 conventional admission records and 248 admission forms, and 274 conventional operation notes and 245 operation forms. The chi-square test, Fisher exact test and unpaired t-test were used (p<0.05). Results: Use of the pre-printed form improved the documentation of fracture side, consent to the operation, causes of operative delay, prophylactic use of antibiotics, duration of the operation, blood loss, pre-fracture walking ability, consumption of tobacco and alcohol and radiographic evaluation of the position of the osteosynthesis and hemialloplastics. There were no differences in the documentation of operation date and site, surgeon, fracture and operation type, allergies or diagnosis at admission. The conventional medical record was superior in recording data about anaesthetics. Discussion: The hip fracture form improved data collection, even though vital data were obtained to the same degree as before. The content of the conventional medical record is based on traditions and reflects the priorities of individual doctors. The pre-printed form facilitates the audit process by collecting prospective and systematized data, and it can provide the basis for a computer-based medical record.