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[Structured documentation of patients' medical records. A new record structure for emergency admissions is coming]
Bo Amdi Jensen1, Lisbeth Rasmussen, Peter Qvist
1Den Gode Medicinske Afdeling-et nationalt kvalitetsudviklingsprojekt. bo.amdi@mail.tele.dk
Introduction:
In recent years a range of efforts to shorten the length of stay (LOS) for patients admitted to hospitals has been tested. Some studies indicate that this might be accomplished by rigorous planning of patient pathways and structured documentation of medical records. In this study the effect of a structured case record model was tested.
Methods:
The new record structure was developed using predefined requirements for content, placement and presentation of documentation. Instruction of staff was followed by a switch to the new model from one day to the next. Collection of data was carried out three months before and five to eight months after implementation of the model.
Results:
The department succeeded in including well over 50% of all includable patients. However, the analysis encompassed all includable patients (''intention to treat'' principle). The number of cases analysed was 340 before and 353 after implementation of the model. Average LOS was reduced by 1.1 day from before implementation to after implementation. This was not statistically significant. However, the model was subsequently kept in use by the department.
Discussion:
This pilot study shows a non-significant tendency to shotening of LOS by using a structured case record model. It is important to pay attention to the practical difficulties of implementing new documentation tools.
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