Documentation of decision-making during air transport.
Air Medical Journal · 2000-01-01 · Observational study
Abstract
INTRODUCTION: Decision-making is an integral part of quality patient care. The aim of this study was to evaluate decision-making documentation. METHODS: A retrospective descriptive design was used to examine the documentation for a convenience sample of 48 trauma patients transported by rotor-wing aircraft. RESULTS: A total of 1012 decisions were documented in the 48 records. The decisions were grouped into major conceptual problems. An average of 10.2 +/- 4.56 conceptual problems were identified in each record. The top 10 conceptual problems were evaluated. Adequate documentation was found to support all decision-making related to the top 10 problems. CONCLUSION: Although air medical personnel may not directly document statements of rationale for their decision-making, sufficient data were present in the records to support each documented decision.