Implementing a tertiary survey in the emergency general surgery population: Imitation is the sincerest form of flattery - 20/06/22
, L. Bonenclark a, c , L. O'Meara a , N. Tobin a, d , B. Bruns a, b , J. Diaz a, b Abstract |
Objectives |
The inherent complexity of the Emergency General Surgery (EGS) patient may preclude precise documentation at admission. To obviate lapses in documentation, an EGS tertiary survey (EGS-TS) was developed to enable early recognition of relevant omissions in documentation and clinical findings. We theorized that the creation of the EGS-TS would promote more thorough clinical documentation.
Methods |
A prospective observational study was performed utilizing an EGS-TS from February 2019 through May 2019. The EGS-TS included physical exam, medication reconciliation, analysis of documentation for accuracy, and review of diagnostic imaging for incidental findings.
Results |
There were 139 EGS admissions during the study period and 108 (78%) received an EGS-TS. Of those who received the EGS-TS, incorrect medication reconciliations (72%), incidental findings (12%), undocumented wounds (11%), and undocumented indwelling catheters were identified (6%).
Conclusion |
Implementation of an EGS-TS triggers a detailed evaluation and reveals opportunities for education, improved adherence to documentation standards, and further research that may guide quality improvement initiatives.
Le texte complet de cet article est disponible en PDF.Highlights |
• | Emergency General Surgery. |
• | Tertiary survey. |
• | Structured patient assessment. |
• | Advanced practice provider. |
• | Quality Improvement. |
Keywords : Emergency general surgery, Tertiary survey, Structured patient assessment, Advanced practice provider
Plan
Vol 224 - N° 1PA
P. 85-89 - juillet 2022 Retour au numéro
Article précédent
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