A clinical audit of the electronic data capture of dementia in ambulance service patient records

Abstract

Abstract published with permission. Background: Dementia is a common diagnosis in older people. It is important to identify and record dementia on emergency call-outs, as it impacts on subsequent care decisions. Ambulance services are changing from paper to electronic patient records, but there are limited data on how frequently and in which sections of the electronic patient record dementia is being recorded. Aims: To audit the proportion of ambulance electronic patient records where dementia is recorded for patients aged (i) 65 and above and (ii) 75 and above, and to describe the sections in the electronic patient record in which dementia is recorded, as there is currently no standardised button or field available. Results: A total of 314,786 electronic patient records were included in the audit, over a one-year period. The proportion of attended calls with ‘dementia’ recorded in the electronic patient record in patients aged 65+ was 13.5%, increasing to 16.5% in patients aged 75+, which is similar to that recorded in previous literature. For patients aged 75+ conveyed to hospital, 15.2% had ‘dementia’ recorded in the electronic patient record, which may indicate under-recording. Recording of dementia between Clinical Commissioning Groups varied between 11.0% and 15.3%. Dementia was recorded in 16 different free-text fields, and 38.4% of records had dementia recorded in more than one field. Conclusion: This audit demonstrates high variability in both the frequency of recording dementia and also the location in the electronic patient record. To ensure consistent recording and ease of retrieval to inform patient care and handover, we propose that the electronic patient record should be modified to reflect paramedics’ needs, and those of the healthcare staff who receive and act on the report. Enhanced training for paramedics in the importance and method of recording dementia is required. Future data will enable accurate monitoring of trends in conveyance, and inform justifications for alternative services and novel referral pathways.