Conclusion
This investigation has highlighted that in notes of patients seen in the resuscitation room, 26% either omit information reported by the ambulance crews or transfer it with changes. The possible causes of these omissions have not been investigated and therefore prompt further work into this part of the patient’s care pathway.
We have concentrated on those patients being assessed in the resuscitation room, who are assessed by a team of doctors and nurses quickly. We have not investigated those patients received in other parts of the Emergency Depart- ment whose assessment may be delayed following triage.
The additional information gathered by the hospital and included in their notes also warrants further investigation.