Introduction: Angina pectoris is a clinical syndrome characterised by episodes of pain or pressure in the anterior chest. It is usually described as a wide, oppressive feeling or constriction in the chest and in the upper abdomen and neck. Primary goals of paramedic care of chest pain patients are to minimise sudden death of myocardial infarction (MI) patients, to prevent the occurrence of MI and limit myocardial damage, as well as preserve myocardial function and prevent complications. Documentation is an important part of decision making in the holistic care of a patient and an irreplaceable tool in communication. It helps to secure multi-professional co-operation and an unbreakable chain of information. Documentation must provide a reliable benchmark for assessing nursing responses and effectiveness of nursing interventions. In paramedic care, the pressing nature of care giving situations is everyday reality and thus documentation highlights the ‘here and now' principle.
Method: The research method was quantitative. Paramedic run reports of 60 chest pain patients from a time period of 6 months were analysed retrospectively by using deductive content analysis. The category system used in the data analysis was based on a series of criteria sentences that were used to examine what was documented in the run reports.
Results: Patients' underlying illnesses were documented in 75% of the cases. Starting point of chest pain was documented from 72% of patients and location of pain from 58%. Nature and continuance of chest pain were described in 53% of the cases, but radiation of pain only in 20%. According to the documentation, 12-lead ECG was taken from 68% of patients but V4R-lead was taken only from 18%. Blood pressure was measured from 97%, pulse from 95% and SaO2 from 88% of patients. Documentation was poor when concerning the response of treatment, which was documented only in 38% of the cases.
Conclusions: Documentation was best when describing chest pain and in the physical examination of patients. However, patients' response to treatment was documented very poorly. Furthermore, despite a semi-structured run report, documentation was not very systematic and it varied significantly between individual paramedics. In the future, documentation practices should be standardised and the importance of documenting response of care emphasised.
