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Resuscitation of the written word: meeting the standard for cardiac arrest documentation.

机译:文字复苏:符合心脏骤停记录标准。

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摘要

The aim of this study was to audit cardiac arrest documentation within a UK teaching hospital, survey the regional use of proformas for data collection, and consider the need for a standardised national template. A prospective audit comparing cardiac arrest documentation to General Medical Council (GMC) professional standards and the 'Utstein' fields was carried out, along with a survey of regional resuscitation officers for the use of standardised templates. The main outcome measures were the design of 'best practice' template using GMC guidelines and the 'Utstein' fields. An audit of medical notes involving a cardiac arrest call against the template was performed. There was limited documentation concerning process, events and outcome of arrest calls, as well as minimal regional use of standard templates or consensus on the essential content of medical documentation. Documentation of cardiac arrests in the Leeds Teaching Hospitals does not meet the 'Utstein' recommendations to provide enough information for audit of cardiac arrest procedure. The regional survey indicates that this problem is likely to be widespread.
机译:这项研究的目的是在英国一家教学医院内对心脏骤停文献进行审核,调查在形式上用于数据收集的地区使用情况,并考虑是否需要标准化的国家模板。进行了前瞻性审核,将心脏骤停文档与通用医学委员会(GMC)的专业标准和'Utstein'领域进行了比较,并对区域复苏官员使用标准化模板的情况进行了调查。主要结果指标是使用GMC准则和“ Utstein”字段设计“最佳实践”模板。对该模板进行了涉及心脏骤停呼叫的医疗记录审核。关于逮捕程序的过程,事件和结果的文件有限,并且对标准模板的最小区域使用或对医疗文件基本内容的共识也很少。利兹教学医院的心脏骤停记录不符合“ Utstein”建议,无法为心脏骤停程序的审核提供足够的信息。区域调查表明,此问题可能会广泛存在。

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