Addressing documentation deficiencies in emergency department records: Implications for fall risk assessment and holistic care in older adults

IF 1.8 4区医学 Q2 NURSING

International Emergency Nursing Pub Date : 2025-05-14 DOI:10.1016/j.ienj.2025.101617

Sara Bergström , Kristina Rosengren , Catarina Wallengren , Ramona Schenell , Hanna Falk Erhag

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引用次数: 0

Abstract

Background

Falls are a substantial threat to public health globally and the leading cause of unintentional injury and death among individuals aged 65 years and older. This study aimed to review the medical records of older patients in an ED after an accidental fall to summarize their documented care process and identify factors associated with hospitalization or discharge to home.

Methods

A retrospective review of medical records (n = 778) was conducted at a university hospital emergency department (ED) in Sweden. Descriptive statistics were used to report patient characteristics and differences in proportions based on information sources, the patient’s inability to state the reason for the fall, and health- care interventions.

Results

The medical records documentation of all professionals focused on medical conditions but lacked information on social background, screening, and status in the ED. Being discharged after a fall accident (55%) was more common than being hospitalized (45%), and most hospitalizations were attributed to medical reasons. There were differences in documentation between hospitalized and discharged. Overall, the medical records of the hospitalized group had more information of patient’s social situations and walking aids than the discharged group.

Conclusion

The results highlight deficiencies in documenting critical patient information within ED medical records. These gaps in medical records hinder the effective assessment and management of fall risk in older adults. Therefore, implementing person-centered care (PCC) with a holistic approach along with fall prevention is essential.

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解决急诊科记录中的文件缺陷：对老年人跌倒风险评估和整体护理的影响

跌落是全球公共卫生的重大威胁，也是65岁及以上老年人意外伤害和死亡的主要原因。本研究旨在回顾意外跌倒后急诊科老年患者的医疗记录，总结其记录的护理过程，并确定与住院或出院回家相关的因素。方法回顾性分析瑞典某大学医院急诊科（ED） 778例病例。描述性统计用于报告患者的特征和基于信息来源的比例差异，患者无法说明跌倒的原因，以及卫生保健干预措施。结果所有专业人员的医疗记录都集中在医疗状况上，但缺乏社会背景、筛查和急诊科状态的信息。因跌倒事故出院的比例（55%）高于住院的比例（45%），大多数住院是由于医疗原因。住院和出院的文献资料有差异。总体而言，住院组病历中有关患者社交情况和助行设备的信息多于出院组。结论研究结果突出了急诊科病历中记录关键患者信息的不足。医疗记录中的这些空白阻碍了对老年人跌倒风险的有效评估和管理。因此，实施以人为本的护理（PCC）与整体方法以及预防跌倒是必不可少的。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

International Emergency Nursing NURSING-

CiteScore

3.20

自引率

11.10%

发文量

期刊介绍： International Emergency Nursing is a peer-reviewed journal devoted to nurses and other professionals involved in emergency care. It aims to promote excellence through dissemination of high quality research findings, specialist knowledge and discussion of professional issues that reflect the diversity of this field. With an international readership and authorship, it provides a platform for practitioners worldwide to communicate and enhance the evidence-base of emergency care. The journal publishes a broad range of papers, from personal reflection to primary research findings, created by first-time through to reputable authors from a number of disciplines. It brings together research from practice, education, theory, and operational management, relevant to all levels of staff working in emergency care settings worldwide.