The Quality of Documentation in Pre-Hospital Emergency Mission Forms; a Cross-sectional Study

As one of the most important departments in the hospital, emergency department is responsible for providing rapid treatment care for reducing mortality and disability among patients. Achieving this aim is possible with managing and evaluating the activities in this department via complete, accurate, and timely documentation of data based on standard principles. Therefore, the present study has been designed with the aim of determining the extent to which documentation standards are adhered to in mission forms of patients in pre-hospital emergencies. By evaluating the mission forms, existing problems can be identified and plans can be made to relieve them. The present study is a cross-sectional one performed on pre-hospital mission forms from March 2017 to March 2018. To gather data, a checklist consisting of 24 questions in 2 parts was used. The first part consisted of 11 questions to determine the extent to which standards of patient characteristics documentation were adhered to and the second part consisted of 14 questions for determining the rate of adherence to documentation standards in mission forms. Based on Likert scale, each question was rated as no answer (1 point), illegible (2 points), incomplete (3 points) and complete (4 points). Therefore, the minimum and maximum obtainable points were considered (11-44) in the section regarding correct documentation of patient characteristics and (14-56) in the mission reports part. Finally, data were analyzed via SPSS statistical software version 18 using chi square and Fisher’s exact tests for comparing qualitative data and student’s t-test for comparing qualitative data. In this study, 250 pre-hospital mission forms were evaluated. Mean score obtained in evaluating the quality of documenting medical orders was 22.4±15.0 (minimum 15 and maximum 34). Mean total score obtained for documentation of mission form reports was 32.0±4.8 (minimum 28 and maximum 46). The overall score of emergency medical services (EMS) mission forms regarding adhering to the standards of documentation was 50.7±5.2 (minimum 45 and maximum 74). Based on the results of the present study, the state and quality of adhering to documentation standards in mission forms of the studied EMS unit was not at a desirable level.