急诊科病历与父母自述创伤性脑损伤症状的比较

Q3 Medicine
Concussion Pub Date : 2018-04-06 eCollection Date: 2018-03-01 DOI:10.2217/cnc-2017-0017
Audrey McKinlay, Alanah Lin, Martin Than
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引用次数: 3

摘要

目的:研究表明急诊科(ED)对创伤性脑损伤(TBI)病例的记录较差。方法:2-12岁儿童因头部受伤到急诊科就诊的家长填写一份脑震荡检查表,并与医疗记录进行比较。结果:急诊科病历中常用的颅脑损伤、脑震荡、轻度颅脑损伤和轻度颅脑损伤,未区分颅脑损伤和浅表性颅脑损伤。回忆起的症状包括呕吐、视力模糊和头痛,而父母报告的脑震荡症状更多的是头痛、疲劳和恶心。与医疗记录相比,从父母回忆中可以识别出更多的TBI病例,而医疗记录在TBI的诊断、预后和统计报告方面记录的症状较少。结论:需要明确的指导方针,以提高回顾性诊断的发病率收集和未来的临床应用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
A comparison of emergency department medical records to parental self-reporting of traumatic brain injury symptoms.

Aim: Studies have shown Emergency Department (ED) recording of traumatic brain injury (TBI) cases to be poor.

Methods: Parents of children aged 2-12 who attended an ED with injury to the head completed a concussion checklist which was compared with medical records.

Results: ED medical records commonly used head injury (HI), concussion, minor-HI and mild-HI without distinction between TBI and superficial HI. Recalled symptoms included vomiting, blurred vision and headaches versus headaches, fatigue and feeling sick from parents who reported more concussive symptoms. More cases of TBI were identifiable from parental recall compared with medical records, which recorded fewer symptoms for diagnosis, prognosis and statistical reporting of TBI.

Conclusion: Clear guidelines need to be implemented to improve retrospective diagnosis for incidence gathering and future clinical use.

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来源期刊
Concussion
Concussion Medicine-Neurology (clinical)
CiteScore
2.70
自引率
0.00%
发文量
2
审稿时长
12 weeks
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