Informationen zur medizinischen Vorgeschichte in der Notaufnahme: Einfluss auf Therapie- und Diagnostikentscheidungen

BACKGROUND: The introduction of an electronic health record (EHR) or an emergency care data set (ECDS), as well as reforms in emergency medical care, is currently part of political debate in Germany. Currently, no data are available of how emergency departments could benefit from an ePA or NFD in Germany. The aim of this study was to determine if a patient’s medical history has an influence on diagnostic and therapeutic decisions in the emergency department. METHODOLOGY: To answer this question, a descriptive observational study was conducted in an interdisciplinary emergency department with a study population of n = 96. RESULTS: For 55 patients (59%) neither a doctor’s letter nor a drug list was found. However, in 48% of the patients who were admitted to the hospital via the emergency department, additions to the anamnesis record could be identified. Eight (9%) patients showed that therapy and/or diagnostic decisions should have been discussed or changed if the supplemented anamnestic information had been available in the emergency room. In addition, the study revealed that the duration of the anamnesis was prolonged in case of missing medical history (mean: 10–15 min, standard deviation: ±<5 min). In contrast to the patients with a medical history (mean: 5–10 min, standard deviation: ±<5 min). CONCLUSION: Based on the data stored in EHR and ECDS, therapy and diagnostic decisions could be made more reliably. In the absence of a medical history, the time required for medical history taking in emergency departments is significantly longer, which could be reduced by introducing EHR or ECDS.