@article{ref1,
title="Standardized collection of presenting complaints in the emergency room : integration of coded presenting complaints into the electronic medical record system of an emergency department and their value for health care research",
journal="Medizinische Klinik, Intensivmedizin und Notfallmedizin",
year="2018",
author="Greiner, F. and Brammen, D. and Kulla, M. and Walcher, F. and Erdmann, B.",
volume="113",
number="2",
pages="115-123",
abstract="BACKGROUND: The point of entry of a patient in emergency care is a symptom or a complaint. To evaluate subsequent processes in an emergency department until a diagnosis is made, this information has to be taken into account. <br><br>OBJECTIVES: We report the introduction of coded presenting complaints into the electronic medical record system of an emergency department and describe the patients based on these data. <br><br>METHODS: The CEDIS presenting complaint list was integrated into the emergency department information system of an emergency department (38,000 patients/year). After 8 months, we performed an exploratory analysis of the most common presenting complaints. Furthermore, we identified the most frequent diagnoses for presenting complaint &quot;shortness of breath&quot; and the most frequent presenting complaints for the diagnosis of sepsis. <br><br>RESULTS: After implementing the presenting complaint list, a presenting complaint code was assigned to each patient. In our sample (26,330 cases), &quot;extremity pain and injury&quot; comprised the largest group of patients (29.5%). &quot;Chest pain-cardiac features&quot; (3.7%) and &quot;extremity weakness/symptoms of cerebrovascular accident&quot; (2.4%) were the main cardiac and neurologic complaints, respectively. They were mostly triaged as urgent (>80%) and hospitalized in critical care units (>50%). The main diagnosis for presenting complaint &quot;shortness of breath&quot; was heart failure (25.1%), while the main presenting complaint for the diagnosis sepsis was &quot;shortness of breath&quot; (18.1%). <br><br>CONCLUSIONS: Containing 171 presenting complaints, this classification was implemented successfully without providing extensive staff training. The documentation of coded presenting complaints enables symptom-based analysis of the health care provided in emergency departments.<p /> <p>Language: de</p>",
language="de",
issn="2193-6218",
doi="10.1007/s00063-017-0286-9",
url="http://dx.doi.org/10.1007/s00063-017-0286-9"
}