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Related Experiment Videos

Updating the accident and emergency record.

H B Casserly1, P Tomas

  • 1Royal Liverpool Hospital, UK.

Injury
|January 1, 1992
PubMed
Summary

Accident and Emergency (A/E) records in the Mersey Region showed significant variation and lacked computerization. Implementing computer-structured A/E records can improve patient information accuracy and transferability.

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Area of Science:

  • Healthcare Informatics
  • Emergency Medicine
  • Medical Record Management

Background:

  • Review of eight records from six Accident and Emergency (A/E) departments in the Mersey Region.
  • Investigation into record structure, printed content, documentation areas for staff, and information transfer capabilities.
  • Assessment of current computer usage in A/E departments.

Purpose of the Study:

  • To evaluate the current state of A/E record-keeping practices.
  • To identify limitations in existing record systems.
  • To explore the potential benefits of computerization in A/E records.

Main Methods:

  • Qualitative review of existing A/E department records.
  • Analysis of record structure and content.
  • Inquiry into the use of administrative, nursing, and medical staff documentation areas.
  • Examination of information transfer efficiency to other departments and general practitioners.
  • Investigation into computer utilization for patient data recording.

Main Results:

  • No uniformity was found in A/E records across the studied hospitals.
  • Only one record included a dedicated section for nursing care documentation.
  • None of the A/E departments utilized computers for patient data recording (delayed or real-time).

Conclusions:

  • Current A/E record systems lack standardization and computer integration.
  • A computer-structured A/E Record system is proposed to enhance legibility and factual accuracy of patient histories, examinations, and care plans.
  • Computerized records would facilitate seamless information transfer within hospitals and to community practitioners.

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