[The use of a pro-forma improves the quality of the emergency medical charts of patients with acute stroke]

Abstract

Introduction: The information obtained from the Emergency Medical Chart (EMC) is a key factor for the correct management of acute stroke. Our aim is to determine if the use of a pro-forma (PF) for filling in the EMC improves the quality of the clinical information.

Material and methods: A PF was created from a list of 26 key-items considered important to be recorded in an EMC. We compared the number of items recorded in the EMC of patients admitted to our Stroke Unit (SU) in January-February 2009 (before PF was introduced) with the data obtained with the PF (April-May, 2009). We also analysed the agreement with the final diagnosis on discharge from the SU.

Results: A total of 128 EMC were analysed, and the PF was used in 48 cases. The mean number of recorded items was 20.5 for the PF group and 13.7 for the non-PF charts (P<.001). Sixteen of the 26 items were recorded significant more frequently (P<.05) in the PF Group. The most notable scores being: previous baseline situation (100% vs. 51%), previous Modified Rankin scale score (94% vs. 1%), time of symptom onset (100% vs. 85%), time of neurological evaluation (100% vs. 39%), NIHSS score (92% vs. 30%), ECG results (88% vs. 59%), time of perform brain scan (60% vs. 1%). Diagnostic agreement: nosological/syndromic diagnosis: PF group: 94%, Non-PF group: 60% (P<.001), topographic diagnosis: PF: 71%, Non-PF: 53% (P=.03), aetiological diagnosis: PF: 25%, Non-PF: 9% (P=.01).

Conclusions: The use of a PF improves the quantity and quality of the information, and offers a better diagnostic accuracy.