Email updates

Keep up to date with the latest news and content from SJTREM and BioMed Central.

Open Access Original research

Usage of documented pre-hospital observations in secondary care: a questionnaire study and retrospective comparison of records

Geir O Knutsen1 and Knut Fredriksen12*

Author Affiliations

1 Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, N-9037, Tromsø, Norway

2 Division of Emergency Medical Services, University Hospital of North Norway, N-9038, Tromsø, Norway

For all author emails, please log on.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:13  doi:10.1186/1757-7241-21-13

Published: 1 March 2013

Abstract

Background

The patient handover is important for the safe transition from the pre-hospital setting to secondary care. The loss of critical information about the pre-hospital phase may impact upon the clinical course of the patient.

Methods

University Hospital Emergency Care registrars answered a questionnaire about how they perceive clinical documentation from the ambulance services. We also reviewed patient records retrospectively, to investigate to what extent eight selected parameters were transferred correctly to hospital records by clinicians. Only parameters outside the normal range were selected.

Results

The registrars preferred a verbal handover with hand-written pre-hospital reports as the combined source of clinical information. Scanned report forms were infrequently used. Information from other doctors was perceived as more important than the information from ambulance crews. Less than half of the selected parameters in pre-hospital notes were transferred to hospital records, even for parameters regarded as important by the registrars. Abnormal vital signs were not transferred as often as mechanism of injury, medication administered and immobilisation of trauma patients.

Conclusions

Data on pre-hospital abnormal vital signs are frequently not transferred to the hospital admission notes. This information loss may lead to suboptimal care.