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Samanburður á MDS-AC skráningu og hefðbundinni sjúkraskrá á bráðadeild á Íslandi og öðrum Norðurlöndum : hluti samnorrænnar rannsóknar

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Authors
Ólafur Samúelsson
Sigrún Bjartmarz
Anna Birna Jensdóttir
Pálmi V. Jónsson
Issue Date
2005-04-01

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Other Titles
Comparison of MDS-AC registration and conventional medical records in Iceland and other Nordic countries. A part of a Nordic study
Citation
Læknablaðið 2005, 91(4):335-41
Abstract
OBJECTIVE: Complex functional decline and comorbid state is an important indicator of outcome for hospital care of older adults. In today acute care it is important to quickly be able to target those who might benefit from geriatric assessment. The MDS-AC is an evaluation system for geriatric acute care patients that records functional impairment and co-morbid states. The object of this study was to compare the MDS-AC registration with the traditional nurses and doctors records for chosen variables important to older patient care in Iceland and other Nordic countries. METHODS: This was a randomised prospective Nordic study. The study took place in Reykjavík, Copenhagen, Umeå, Oslo and Helsinki. Participants in each country were chosen from 75 year old and older patients admitted to acute care medical wards, 160 patients from each country. The results presented here show data from selected variables collected with the MDS-AC instrument version 1,1 in the first 24 hours of admission, compared with hospital notes for the first 48 hours. RESULTS: For ADL and IADL impairments the medical record missed between 20 to 96% of items registered with the MDS-AC and between 33 to 100% when there is no impairment detected. This was true for all the participating Nordic countries but the Icelandic medical records were in comparison more often incomplete for the variables chosen. CONCLUSION: The MDS-AC documents better than traditional medical records several important variables relating to function among the elderly. It may be possible to improve documentation with a standardized instrument such as the MDS-AC.
Tilgangur: Fjölþættur vandi og færniskerðing eru mikilvægir spáþættir fyrir horfur eldri sjúklinga eftir bráð veikindi. Til að sjúkrahúsþjónusta verði skilvirk og fullnægjandi er mikilvægt að greina þá fljótt sem hefðu ávinning af heildrænu öldrunarmati við bráð veikindi. Minimal Data set for Acute Care (MDS AC) er tæki til heildræns öldrunarmats á bráðasjúkrahúsum. Í þessari rannsókn er hefðbundin skráning lækna og hjúkrunarfræðinga á bráðadeild borin saman við skráningu með MDS-AC tækinu á Íslandi og öðrum Norðurlöndum. Efniviður og aðferð: Rannsóknin var framkvæmd á bráðalyflæknisdeildum sjúkrahúsa í Reykjavík, Umeå, Kaupmannahöfn, Oslo og Helsinki. Í hverju landi voru valdir 160 bráðasjúklingar 75 ára og eldri með slembiúrtaki. MDS-AC gerð 1,1, var notuð við gagnasöfnun. MDS-AC skráning fyrstu 24 klukkustundir í legunni var borin saman við hefðbundna skráningu lækna og hjúkrunarfræðinga fyrstu 48 klukkustundirnar. Niðurstöður: Skráningu á færnitengdum atriðum hjá öldruðum vantar í hefðbundna sjúkraskrá í 20 til 96% tilfella þegar skerðing er til staðar og 33 til 100% tilfella þegar skerðing er ekki til staðar borið saman við MDS-AC. Svipað mynstur sést á öllum Norðurlöndunum en skráning er í mörgum atriðum lakari á Íslandi. Ályktun: MDS-AC skráir betur en hefðbundin sjúkraskrá mörg mikilvæg atriði tengd færni hjá öldruðum. Til álita kemur að bæta skráningu færni­atriða og meðvirkra sjúkdóma með stöðluðu mats­tæki eins og MDS-AC.
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