Introduction, aim: Quality control of patient documentation for cerebral palsy (CP) at Semmelweis University.
Method: In our retrospective audit, we revised patient records for all children born between 2005 and 2015, with suspected CP, registering 673 cases with confirmed CP. Based on the available patient data, we assessed clinical and etiological classification of CP and data availability.
Results: Patient records of 86% of children were suitable for clinical classification. Among them, 90.5% were spastic, 7.8% hypotonic, 1.2% dyskinetic and 0.5% ataxic. Among the classifiable spastic cases (98% of all spastic cases), 51% presented with tetraparetic/tetraplegic, 26% diparetic/diplegic and 23% hemiparetic/hemiplegic localization; in the remaining 2%, sufficient data for topological classification was unavailable. Severity assessed on Gross Motor Function Classification System was definable in 82% of cases, 43% showing grade I-II, 28% grade III and 29% grade IV-V impairment. Patient history was specified in 91% of cases. Prematurity was documented in 55%, perinatal asphyxia/hypoxic-ischemic encephalopathy in 31%, intraventricular/intracranial haemorrhage in 27%, multiple births in 19%, intrauterine growth restriction in 18%, intrauterine/perinatal/infancy infection in 15%, congenital malformation in 12%, in vitro fertilisation in 5%, stroke in 3% and CP-associated genetic mutation in 3% of cases. Negative patient history was determined in 16% of children.
Conclusions: Our audit established that clinical documentation of CP is performed based on uniform criteria, detecting missing data primarily in clinical classification and patient history. We propose a patient documentation standard in the clinical care of affected children, which is a prerequisite for unified data recording and a future national CP registry. Orv Hetil. 2020; 161(21): 873-880.
Keywords: cerebral palsy; cerebralis paresis; minőségi ellenőrzés; mobility impairment; mozgáskorlátozottság; perinatal damage; perinatalis inzultus; quality control.