Hostname: page-component-848d4c4894-m9kch Total loading time: 0 Render date: 2024-05-16T02:49:21.426Z Has data issue: false hasContentIssue false
  • English
  • Français

Vital Signs Records Omissions on Prehospital Patient Encounter Forms

Published online by Cambridge University Press:  28 June 2012

Robert L. Moss
Robert L. Moss*
Affiliation:
Office of Emergency Medical Services, Planning and Development Coordinator, Arizona Department of Health Services, Division of Emergency Medical Services, Phoenix, Ariz.
*
Arizona Department of Health Services/EMS, 100 West Clarendon, Suite 620, Phoenix, AZ 85013USA
Get access Rights & Permissions [Opens in a new window]

Abstract

Introduction:

A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system.

Methods:

The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events.

Results:

Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records.

Conclusion:

This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue.

Keywords

assessmentdispatch typesemergency medical servicesemergency medical techniciansoptical scanvital signs
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 8 , Issue 1 , March 1993 , pp. 21 - 27
Copyright
Copyright © World Association for Disaster and Emergency Medicine 1993

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Spaite, DW, Criss, EA, Valenzuela, TD, et al. : A prospective evaluation of prehospital patient assessment by direct in-field observation: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1990;5:325–334.CrossRefGoogle Scholar
2. McSwain, NE: Letter to editor: A prospective evaluation of prehospital patient assessment by direct in-field observations: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1991;6:75.CrossRefGoogle Scholar
3. Butman, AM: Letter to editor: A prospective evaluation of prehospital patient assessment by direct in-field observations: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1991;6:73–75.CrossRefGoogle Scholar
4. Worsing, RA: Articles of interest: Editor's note: A prospective evaluation of prehospital patient assessment by direct in-field observations: Failure of ALS personnel to measure vital signs. AAOS Emg Svcs Newsletter 1991;Mar:5.Google Scholar
5. Paris, PM: Editorial comment: A prospective evaluation of prehospital patient assessment by direct in-field observations: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1990;5:333.CrossRefGoogle Scholar
6. Olson, J: Editorial comment: A prospective evaluation of prehospital patient assessment by direct in-Field observations: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1990;5:333–334.Google Scholar
7. Spaite, DW, Criss, EA, Valenzuela, TD, et al. : Responds to editor: A prospective evaluation of prehospital patient assessment by direct in-field observations: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1991;6:76.CrossRefGoogle Scholar
8. Arizona Administrative Code: Ambulance Service Licensure, surface, air, water Ambulance service general responsibilities. Phoenix: Arizona Department of State, 1983.Google Scholar
9. Joyce, SW, Witzke, D, Brown, D, et al. : Development of an optically scanned EMS reporting form and database for statewide use. Ann Emerg Med 1987;16:508. Abstract.Google Scholar
10. Joyce, SW, Brown, D: An optically scanned EMS reporting form and analysis system for statewide use: Development and five years experience. Ann Emerg Med 1991;20:1325–1330.CrossRefGoogle ScholarPubMed
11. U.S. Census Bureau: 1990 Census of population. Phoenix: Arizona Department of Economic Security, 1991.Google Scholar
12. Augustine, J, Paris, P, Pappas, G: Emergency medical services communication. In: Kuehl, AE, (ed) EMS Medical Directors Handbook. St Louis: CV Mosby, 1989, pp 49–58.Google Scholar
13. Spaite, DW, Hanlon, T, Criss, EA, et al. : Prehospital data entry compliance by paramedics after institution of a comprehensive EMS data collection tool. Ann Emerg Med 1990;19:1270–1273.CrossRefGoogle ScholarPubMed
14. Valenzuela, TD: EMS data collection: Filling in the dots. Ann Emerg Med 1991;20:1381–1382. Editorial.CrossRefGoogle ScholarPubMed