Preformatted admission charts for poisoning admissions facilitate clinicalassessment and research

Study objective: The assessment of patients with poisoning should include a ssessment of psychiatric details, the level of consciousness, and clinical features occurring in a number of toxidromes (toxicology syndromes). To ens ure these aspects were routinely covered, we introduced a preformatted char t (PFC) to record our poisoning admissions. The aim of our study was to det ermine whether using a PFC improved the quality, accuracy, and completeness of the data obtained from admissions with poisoning. Methods: Clinical details recorded on patients admitted with tricyclic anti depressant, neuroleptic, or carbamazepine poisoning between 1987 and 1994 w ere compared according to whether a PFC was used. A large number of items o f history and examination of interest in poisonings were analyzed. The repr oducibility of the findings recorded on the PFCs was measured in 20 patient s. Findings initially recorded on the chart in the emergency department wer e compared with those recorded within the next 30 minutes by a second more experienced observer who did not have reference to the initial record. Results: There were large and statistically significant differences in the completeness of recording of neurologic examination, such as pupil size (10 0% versus 68%), conjugate eye movements (97% versus 35%), deep tendon refle xes (97% ver sus 51%), and in the percentage that were reported as having a bnormal signs, such as dilated pupils (26% versus 14%), nystagmus (12% vers us 5%), and hyperreflexia (19% versus 8%). In all cases, more information w as recorded when a PFC was used; however, the differences were small for it ems such as vital signs and drugs ingested. Agreement between 2 observers f or history and examination was moderate to good, with items on history and level of consciousness generally recorded with greater agreement than other examination findings, perhaps reflecting fluctuations in these signs. Conclusion: Data collected prospectively with a PFC collects more informati on than can be obtained retrospectively from case records. In particular, t he validity of data on clinical signs on presentation gained from retrospec tive chart review is questionable. Centers that are interested in collectin g data an series of poisonings would benefit from using a PFC or some other systematic prospective method of data collection.