[Medical record--insufficient source of information about patients treated for stroke].
The complete hospital notes made by physicians, nurses and paramedics for 123 patients diagnosed with stroke were studied in order to assess whether the information was sufficient for transfer to a new caregiver. A checklist was designed to include information of importance for the planning of subsequent medical care, rehabilitation and prevention. The questions covered the following areas: social situation, next of kin, current status and physical condition, risk factors, information to the patient, contact with social services, medication and planning. The results revealed missing as well as duplicated information. Apart from the notes written by physicians, additional information was not found to be of use, with the exception of information on next of kin, current status and physical condition.
Hassler
Ejda
E
Centrum för allmänmedicin, Stockholm. ejda.hassler@klinvet.ki.se
Krakau
Ingvar
I
D003266:Continuity of Patient Care; D006801:Humans; D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009737:Nursing Records / Q000592:standards*; D010347:Patient Care Planning; D010360:Patient Transfer; D010808:Physical Examination; D012307:Risk Factors; D012959:Socioeconomic Factors; D020521:Stroke / Q000451:nursing / Q000628:therapy*; D000071939:Stroke Rehabilitation