Problems Existing in Pre-hospital Emergency Medical Records and Evaluation of the Effect of Improvement Measures

Abstract

AbstractObjective. To discuss the problems in pre-hospital emergency medical records in a hospital and analyze the differences in medical record quality before and after taking improvement measures. Methods. We started taking the corresponding improvement measures in January 2013, and analyzed differences in the quality of pre-hospital emergency medical records before (from February 2012 to July 2012) and after (from February 2013 to July 2013) improvement. Results. The medical records from February 2012 to July 2012 were not stored electronically; the non-standard filling rate of general items, the non-standard filling rate of progress note, and proportion of treatment measures that were too simplistic were significantly lower than those before improvement; the pre-hospital emergency medical records from February 2013 to July 2013 were stored electronically; there were no cases lacking handover records after improvement; the general items, progress notes and hand-over records showed obvious improvement a...