Table 2 Data elements documented/not documented in the triage forms
From: Data quality assessment in emergency medical services: an objective approach
Status Data element | Documented Fr (%) | Not documented Fr (%) | Not applicable Fr (%) | |
|---|---|---|---|---|
Patient data | Name | 384 (100) | 0 | 0 |
Surname | 384 (100) | 0 | 0 | |
Admission date | 384 (100) | 0 | 0 | |
Admission time | 384 (100) | 0 | 0 | |
Age | 363 (94.5) | 21 (5.5) | 0 | |
Sex | 365 (95) | 19 (5) | 0 | |
Pregnant | 0 | 0 | 384 (100) | |
Referral method | 361 (94) | 23 (6) | 0 | |
Chief complaint | 381 (99.2) | 3 (0.8) | 0 | |
Drug and food allergies | 187 (48.7) | 197 (51.3) | 0 | |
Triage level | 384 (100) | 0 | 0 | |
Life-threatening conditions | Level of consciousness | 7 (1.8) | 3 (0.8) | 374 (97.4) |
Airway hazard | 2 (0.5) | 8 (2.1) | 374 (97.4) | |
Respiratory distress | 3 (0.8) | 7 (1.8) | 374 (97.4) | |
Cyanosis | 3 (0.8) | 7 (1.8) | 374 (97.4) | |
Shock symptoms | 1 (0.3) | 9 (2.3) | 374 (97.4) | |
Blood oxygen saturation level < 90 | 2 (0.5) | 8 (2.1) | 374 (97.4) | |
High-risk conditions of | Lethargy and drowsiness | 2 (0.5) | 34 (8.9) | 348 (90.6) |
Severe pain or distress | 3 (0.8) | 33 (8.6) | 348 (90.6) | |
Medical history | 80 (20.8) | 304 (79.2) | 0 | |
Medication history | 60 (15.6) | 324 (84.4) | 0 | |
Vital signs | Blood pressure | 301 (78.4) | 48 (12.5) | 35 (9.1) |
Respiration rate | 176 (45.8) | 173 (45.1) | 35 (9.1) | |
Pulse rate | 222 (57.8) | 127 (33.1) | 35 (9.1) | |
Temperature | 67 (17.5) | 282 (73.4) | 35 (9.1) | |
Blood oxygen saturation level | 245 (63.8) | 104 (27.1) | 35 (9.1) | |
Referral data | Referral ward | 370 (96.4) | 14 (3.6) | 0 |
Referral time | 264 (68.8) | 120 (31.2) | 0 | |
Referral date | 281 (73.2) | 103 (26.8) | 0 | |
The name of the triage nurse | 366 (95.3) | 18 (4.7) | 0 | |
Triage nurse signature | 341 (88.8) | 43 (11.2) | 0 | |