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Table 2 Case examples for each category

From: A first look at consistency of documentation across care settings during emergency transitions of long-term care residents

Category

Trigger events that lead to transfer

EMS chief complaint

ED chief complaint

Diagnosis in ED

Consistent (n = 281):

 

Fall(s)

Hip/Pelvis/Back Pain

Hip/Pelvis/Back Pain

Hip/pelvis fracture

 

Short of Breath

Short of Breath

Short of Breath

Heart failure

 

Leg Pain/Cramps/Swelling

Leg Pain/Cramps/Swelling

Leg Pain/Cramps/Swelling

Cellulitis

Ambiguous (n = 83):

 

Sudden Change in Physical Condition

Change in Level of Consciousness

Change in Level of Consciousness

Pneumonia

 

Sudden Change in Physical Condition

General Malaise/Weakness

General Malaise/Weakness

Urinary Related Disease

 

Sudden Change in Physical Condition

Gastro-intestinal (GI) Bleed

GI Bleed

GI Bleed

Insufficient reporting (n = 44):

 

Not Recorded/No Data Available/Illegible

Head/Neck trauma

Head/Neck Trauma

Head Contusion/Laceration

 

Not Recorded/No Data Available/Illegible

General Malaise/Weakness

General Malaise/Weakness

General Malaise/Weakness

 

Chest Pain

Not Recorded/No Data Available/Illegible

Chest Pain

Cardiac Arrythmia

 

Fever

Transfer

Urinary Related Disease

Urinary Related Disease

Disease progression (n = 104):

 

Fall(s)

Change in Level of Consciousness

Confusion/Delirium

Stroke

 

Cough with Congestion

Short of Breath

Cough with Congestion

Respiratory Related Illness

 

GI Bleed

Short of Breath

Short of Breath

Cardiac/Respiratory Failure

 

Urinary Related Disease

Change in Level of Consciousness

Cardiac Arrythmia

Urinary Related Disease

Unclear (n = 79):

 

Fall(s)

Urinary Related Disease

Constipation/Bloating/Abdominal Pain

Constipation/Bloating/Abdominal Pain

 

Change in Behaviour (agitation, aggression)

Mental Health Issues/Psychiatric Issues

General Malaise/Weakness

Dementia

 

Short of Breath

Bleeding

Urinary Related Disease

Sepsis

 

Constipation/Bloating/Abdominal Pain

Musculoskeletal Pain

Nausea/Vomiting/Diarrhea

Fall(s)

 

Fall(s)

Swallowing

Medical Device Problem

Pulmonary Embolism