The purpose of this study is 1) to evaluate the extent to which documentation of the medical record is completed for dependent children who present for evaluation of an acute injury, and 2) to examine the factors that favorably or adversely influence completion of the medical record.
The emergency department (ED) ledgers of 669 children less than nine years of age were reviewed, including 172 (25.7%) who presented for evaluation of an acute injury.
Each of the latter charts was examined for basic demographic data, as well as information about injury type and mechanism, ED provider, and involvement of social services personnel.
The ledgers were further examined to determine completeness of chart documentation in several relevant areas, including the circumstances and characteristics of the acute injury, pertinent past medical history, and course of management and referral while in the ED.
Each of 15 individual documentation variables was assigned a score of either zero (incompletely/not addressed or documented) or one (completely addressed or documented).
The 15 individual scores were equally weighted and summed, resulting in a total documentation score ranging from zero (failure to address or document any of the 15 variables) to 15.
(all variables completely addressed/documented).
Mots-clés Pascal : Traumatisme, Enfant, Homme, Urgence, Service hospitalier, Conservation document, Education, Parent, Prévention
Mots-clés Pascal anglais : Trauma, Child, Human, Emergency, Hospital ward, Document preservation, Education, Parent, Prevention
Notice produite par :
Inist-CNRS - Institut de l'Information Scientifique et Technique
Cote : 95-0227432
Code Inist : 002B16N. Création : 09/06/1995.