title: Adequacy of immediate care documentation at a major United Kingdom endurance event.
abstract: The objective of this study was to determine the rate of major omissions from documentation in a prehospital environment. Analysis of 251 competitor records, documented over 2 years from four consecutive UK outdoor endurance events (2006-2007), was performed. Eighty-two percent of case notes were found to be of adequate quality (n = 206), with 15% containing minor omissions (n = 37, i.e. omissions of some patient details) and 3% containing major omissions (n = 8, i.e. no details of diagnosis/treatment). Of the major omissions, first aiders and health-care professionals (doctors and nurses) made the same number of errors (n = 4 each, P = 0.7), but first aiders made significantly more minor omissions (n = 31 vs. 6, P<0.001). From 25 patients who needed medication, only one prescription error occured. In conclusion, accurate documentation is achievable at prehospital mass gathering events. First aiders made no more major documentation omissions than health-care professionals, but made more minor omissions. Standardized proformas may help reduce this rate and improve efficiency.
authors.affiliation: University of Birmingham, West Midlands, Birmingham, UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Pickard
authors.forename: Catherine
authors.initials: C
authors.lastname: Agar
authors.forename: Lucilla
authors.initials: L
authors.lastname: Butler
authors.forename: Aneel
authors.initials: A
authors.lastname: Bhangu
mesh_terms: D004282:Documentation / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005240:Feasibility Studies; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D010807:Physical Endurance; D011787:Quality of Health Care; D012720:Severity of Illness Index; D013177:Sports; D014218:Triage / Q000706:statistics & numerical data*; D006113:United Kingdom