Profile of documented medical history of chest pain: a multicentre audit of 1,226 consecutive patients with validated acute MI

摘要

This study set out to evaluate the completeness of medical records of chest pain. A planned, multicentre, structured abstraction of data from case-notes was made at 20 adjacent acute hospitals in Yorkshire on 1,226 consecutive patients presenting with chest pain and validated myocardial infarction (Ml). The hospital records included those collected by ambulance crews, accident and emergency staff, and admitting medical teams. The main outcome measure was completeness of medical records with regard to 10 commonly advocated descriptors of chest pain.A mean number of 5.62 chest pain descriptors was recorded. This value differed with hospital (range 4.81 to 6.73 factors recorded; p<0.0001); place of admission (medical admissions unit = 6.10; coronary care unit 5.94; accident & emergency department = 5.62; general ward = 5.08; p<0.0001); gender (male = 5.74; female = 5.39; p=0.004) and age (=< 68.4 years = 5.83; > 68.4 years = 5.43; p<0.0001). Mean chest pain scores were also significantly different for District General Hospitals (DGHs) without angiography facilities as compared to DGHs with angiogram facilities and tertiary centres (respectively 5.46 vs. 5.81 vs. 5.81 p<0.007).Contrary to standard medical texts and teaching, we observed that documentation of chest pain histories was abbreviated in many cases.