救護技術員填寫救護紀錄表之探討

An Analysis of Prehospital Care Records Produced by Emergency Medical Technicians in Taipei

葉時烊(Shih-Yang Yeh) ； 廖訓禎(Shiumn-Jen Liaw) ； 胡百敏(Pai-Min Hu) ； 張玉龍(Yu-Lung Chang)

《中華民國急診醫學會醫誌》 2卷2期 (2000/09) Pp. 8-14

摘要

台北醫療區域醫療網及台北市政府衛生局於民國八十七年十二月一日至八十八年一月十五日，委託台北市急救責任醫院將119救護技術員所填寫之救護紀錄表在急診現場予以評估。共回收927份有效評估表，結果顯示對於常規性的基本資料填寫尚稱完整，但對病患的評估，如第一次生命徵象未填寫的佔了22.0%至30.1%，第二次生命徵象未填寫的更高達50.4%至54.1%，表示救護技術員似乎並未落實病患評估之紀錄；在處置方面，氧氣的給予仍有29%未適切記錄執行，而有63.2%的到院前死亡者，似乎未執行心肺復甦術；因此實有必要加強對救護紀錄表的考核，以促進到院前緊急救護處置及紀錄之落實，如此本國之緊急醫療救護服務品質才能相對提昇，進而增進全民之福祉。

關鍵字

緊急醫療救護服務 ； 救護技術員 ； 救護紀錄表

並列摘要

Between December 1998 and January 1999, the Taipei Medical Care Network and the Taipei Public Health Office gathered and analyzed prehospital care records from hospitals with emergency facilities in Taipei. In total, 927 prehospital care records were collated and the quality of emergency care documented by these records evaluated. The general data for ambulance care patients were recorded almost intact. Vital signs were not initially recorded in 22.0% to 30.1% of cases, and records of the second set of vital sign observations were less reliable again, only to be found in 50.4% to 54.1% of cases. This suggests that there is room for improvement in prehospital care documentation. In 29% of cases, oxygen was not delivered at sufficient rates. Cardiopulmonary resuscitation following out-of-hospital cardiac arrest was not performed in 63.2% of cases, in all likelihood increasing patient mortality. These results highlight the need for improved standards of prehospital care documentation in Taiwan, which should help to improve patient management in emergency medical care facilities.

並列關鍵字

emergency medical service ； emergency medical technician ； prehospital care records