Documentation of clinical review and vital signs after major surgery

Medical Journal of Australia

Volumn 189, Issue 7, 2008, Pages 380-383

  McGain, Forbes ^a   Cretikos, Michelle A ^b   Jones, Daryl ^c   van Dyk, Susan ^d   Buist, Michael D ^d   Opdam, Helen ^e   Pellegrino, Vincent ^c   Robertson, Megan S ^c,f   Bellomo, Rinaldo ^e  

^a WESTERN HOSPITAL   (Australia)

^b CENTRE FOR EPIDEMIOLOGY AND RESEARCH   (Australia)

^c ALFRED HOSPITAL   (Australia)

^d DANDENONG HOSPITAL   (Australia)

^e AUSTIN HOSPITAL   (Australia)

^f ROYAL MELBOURNE HOSPITAL   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; AGED; BLOOD PRESSURE MEASUREMENT; BODY TEMPERATURE MEASUREMENT; BREATHING RATE; CLINICAL ARTICLE; CONTROLLED STUDY; EPIDURAL ANESTHESIA; FEMALE; HEART RATE; HUMAN; MAJOR SURGERY; MALE; MEDICAL AUDIT; MEDICAL DOCUMENTATION; MEDICAL RECORD REVIEW; NURSING CARE; OXYGEN SATURATION; PATIENT CONTROLLED ANALGESIA; POSTOPERATIVE CARE; POSTOPERATIVE PERIOD; QUALITY CONTROL; RETROSPECTIVE STUDY; REVIEW; VITAL SIGN; WORKING TIME;

EID: 55449086046     PISSN: 0025729X     EISSN: None     Source Type: Journal    
DOI: 10.5694/j.1326-5377.2008.tb02083.x     Document Type: Review

References (27)

1. Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Intern Med J 2001; 31: 343-348.
2. Kause J, Smith G, Prytherch D, et al; Australian and New Zealand intensive Care Society Clinical Trials Group. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom. The ACADEMIA study. Resuscitation 2004; 62: 275-282.
3. Goldhill DR, White SA, Sumner A. Physiological values and procedures in the 24 In before ICU admission from the ward. Anaesthesia 1999; 54: 529-534.
4. Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analysing responses of physicians and nurses in the hours before the event. Crit Care Med 1994; 22: 244-247.
5. Schein RM, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990, 98: 1388-1392.
6. McNicol L, Story DA, Leslie K, et al. Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals. Med J Aust 2007; 186: 447-452.
7. James K, Bellomo R, Poustie S, et al. The epidemiology of major adverse physiological events after surgery. Crit Care Resusc 2000; 2: 108-113.
8. Hillman K, Chen J, Cretikos M, et al; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005; 365: 2091-2097.
9. Alcock K, Clancy M, Crouch R. Physiological observations of patients admitted from A and E. Nurs Stand 2002; 16: 33-37.
10. Nurmi J, Harjola VF, Nolan J, Castrén M. Observations and warning signs before cardiac arrest. Should a medical emergency team intervene earlier? Acta Anaesthesiol Scand 2005; 49: 702-706.
11. McBride J, Knight D, Piper J, Smith GB. Long-term effect of introducing an early warning score on respiratory rate charting on general wards. Resuscitation 2005; 65: 41-44.
12. Helliwell VC, Hadfield JH, Gould T. Documentation of respiratory rate for acutely sick hospital inpatients - an observational study. Intensive Care Med 2002; 28 Suppl 1: S21.
13. Hudson A. Prevention of in hospital cardiac arrests-first steps in improving patient care. Resuscitation 2004; 60: 113.
14. Edwards SM, Murdin L. Respiratory rate - an under-documented clinical assessment. Clin Med 2001; 1: 85.
15. Chellel A, Fraser J, Fender V, et al. Nursing observations on ward patients at risk of critical illness. Nurs Times 2002; 98 (46): 36-39.
16. Subbe CP, Davies RG, Williams E, et al. Effect of introducing the Modified Early Warning Score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia 2003; 58: 797-802.
17. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346: 1128-1137.
18. Haberman S, Rotas M, Perlman K, Feldman JG. Variations in compliance with documentation using computerized obstetric records. Obstet Gynecol 2007; 110: 141-145.
19. Baigrie RJ, Dowling BL, Birch D, Dehn TC. An audit of the quality of operation notes in two district general hospitals. Are we following Royal College guidelines? Ann R Coli Surg Engl 1994; 76: 8-10.
20. Friedman MT, Ebrahim A. Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness. Arch Path Lab Med 2006; 130: 474-479.
21. Kumar P. Physician documentation of neonatal risk assessment for perinatal infections. J Pediatr 2006; 149: 265-267.
22. Miller P, Pastorino C. Daily nursing documentation can be quick and thorough. Nurs Man 1990; 21 (11): 47-52.
23. Howse E, Bailey J. Resistance to documentation - a nursing research issue. Int J Nurs Stud 1992; 29: 371-380.
24. Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. Int J Nurs Pract 2006; 12: 366-374.
25. Cretikos M, Chen J, Hillman K, et al; MERIT study investigators. The objective medical emergency team activation criteria: a case-control study. Resuscitation 2007; 73: 69-72.
26. Cretikos MA, Bellomo R, Hillman K, et al. Respiratory rate: the neglected vital sign. Med J Aust 2008; 188: 657-659.
27. Buist M, Bernard S, Nguyen TV, et al. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004; 62: 137-141.