Standardization of Patients Records

A patient's care depends on good medical records, and prehospital records are no exception. All ambulance services within a specific region should use a similar reporting form that can be quickly and easily interpreted by receiving nurses and physicians. It is more difficult to standardize emergency department records. However, flow sheets that are easily interpretable by receiving physicians and nurses can be used. Uniform data elements for EMS care have been developed by the NHTSA and are coming into common use.3 Uniform data elements for emergency department care have also been developed by a cooperative effort among the NHTSA, the Centers for Disease Control, and many emergency medical organizations. It is wise to design record systems that facilitate data extraction for trauma registries, severity scoring, and cardiac arrest outcome studies.

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