Pinet PLM

Language: Spanish
References: 17
Page: 37-43
PDF size: 68.92 Kb.

ABSTRACT

Objective: To describe the integrity of patient care reports and its relation with patient care standards documented in one ambulance service, considering total transportation times, chief complaint, personal protective devices, treatment and level of care based on the patient care report. Material and methods: We used prehospital reports from adult patients. The data gathered included age/gender, total transport times, chief complaint, personal protection, treatment and level of care reported. The information was stored and analyzed with SPSS® statistical package, version 12.0.0 through frequencies and cross tabulations. Results: A total of 59 reports were identified. Eight (3.5%) reports did not include the type of service, while 2% did not include age or gender. Total transport times were not documented in 35.6% of the reports and 30.5% did not specify chief complaint. Personal protection was not documented in only 5 (8.5%) reports but differential diagnosis was documented in only 2.9% of them. Conclusions: It is necessary to obtain a complete, clear and neat report for each patient, which includes a complete assessment, without excluding information that appears to be irrelevant.

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