title: The development of a quality assessment tool for ambulance patient care records.
abstract: A retrospective cohort study of the 2002 Victorian prehospital emergency care documentation completed by ambulance paramedics had the objectives: (i) to design and implement a quality assessment tool to determine the quality of the ambulance patient care record (PCR)information; and (ii) to identify critical demographic and clinical items on the ambulance PCR that needed improvement. The study outcomes included a functioning quality assessment tool and associated user guide for prehospital use, and the identification of three critical PCR components requiring improvement. Ninety percent of PCRs passed the quality assessment; 10% (approximately 5 300) contained measurably poor or incomplete documentation.
authors.affiliation: Centre for Ambulance and Paramedic Studies, Monash University, Peninsula Campus, McMahons Rd, Frankston VIC 3199, Australia. erin.smith@med.monash.edu.au
authors.forename: Erin
authors.initials: E
authors.lastname: Smith
authors.forename: Mal
authors.initials: M
authors.lastname: Boyle
authors.forename: James
authors.initials: J
authors.lastname: MacPherson
mesh_terms: D000552:Ambulances / Q000458:organization & administration / Q000592:standards*; D019985:Benchmarking; D004634:Emergency Medical Technicians / Q000592:standards*; D005568:Forms and Records Control / Q000592:standards; D006302:Health Services Research; D006801:Humans; D019451:Information Management / Q000458:organization & administration / Q000592:standards*; D008499:Medical Records / Q000592:standards*; D015397:Program Evaluation / Q000379:methods; D011786:Quality Control; D012189:Retrospective Studies; D014218:Triage; D014739:Victoria