[Optimized documentation entry in emergency care using pen computers--initial results].
OBJECTIVE
Recently, documentation systems based on portable personal computers have become available for application in prehospital emergency medicine. The aim of the present study was to compare a handwritten record system with a pen-computing assisted documentation system.


METHODS
52 consecutive jobs of the local mobile intensive care unit (MICU) were recorded both by means of a handwritten record and by use of a pen-computer-assisted documentation system (NAPROT, based on DIVI-documentation system version 2.5). The paramedic performing pen-computing was obliged to restrict data inputs to those moments during which emergency physician was able to fill in his record. NAPROT routinely checked the records derived from the pen-computer for completeness of data before print-out.


RESULTS
Neither hardware nor software problems occurred. Compared to the handwritten records the electronic documentation system resulted in a significant increase in recorded data. The following parameters were recorded more frequently by means of the new method of documentation: Glasgow Coma Score (47 vs 36 patients), positioning manoeuvres (36 vs 19 patients), blood glucose level (25 vs 17 patients), and complications (13 vs. 4 events).


CONCLUSIONS
Pen-computing assisted documentation resulted in superior quality of data recorded in emergency medical files. This increase in information may be ascribed to the integrated check for completeness of data. The described new documentation system, therefore, enhances the processing quality in prehospital emergency medicine. Further developments of the documentation system should concentrate on tools while reducing the workload of the emergency physician.
Ellinger
K
K
Institut für Anästhesiologie und Operative Intensivmedizin, Fakultät für Klinische Medizin Mannheim, Universität Heidelberg.
Luiz
T
T
Obenauer
P
P
D000552:Ambulances; D004282:Documentation / Q000379:methods*; D004632:Emergency Medical Services; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000295:instrumentation*; D008838:Microcomputers; D008991:Monitoring, Physiologic / Q000295:instrumentation; D011785:Quality Assurance, Health Care; D012984:Software