In order to ensure the accuracy of the data collected for the medical record, the training of nurses and physicians should emphasize the importance of the general assessment of symptoms, provide interview techniques to help patients determine the date of onset of symptoms and emphasize the value of a complete documentation. A comprehensive interview guide to understanding the full experience of symptoms, including atypical symptoms, the period during which the patient first noticed symptoms of 10 minutes or more, and the period during which symptoms became constant prior to presentation at the hospital would be helpful to nurses and physicians who first come into contact with these patients. The maintenance guide should be user-friendly and effective for patients and providers and treat medical records in a transparent manner to avoid delaying the assessment, diagnosis and treatment of ACS in a timely manner. The use of quality improvement initiatives (for example. B the ACTION®-GWTG™ register for patients with ACS, developed by the National Cardiovascular Data Registry10) to track the start of symptoms for patients with ACS can also help improve data integrity. In addition, observational studies could be used in real time to determine whether patient reactions are well documented in the recording. In addition to a consistent surgical definition of the onset of symptoms, there should be consistency in how the data (date of onset of symptoms) is collected by the patient with symptoms. Patient-related factors influence accurate assessment and documentation. For example, some patients minimize or hide symptoms. Some patients are unable to determine the period of onset of symptoms due to vague, intermittent or less intense symptoms. At other times, patient instability may affect the patient`s ability to answer questions. Care factors such as variations in the assessment/interview technique, experience with acS patients, and the relationship between nurses and patients can also influence accurate assessment and documentation of the onset of symptoms.
In addition, systemic factors, such as . B, differences in documentation methods, ranging from the use of physical copies to computerized clinical documentation systems, can influence the completeness and accuracy of the data.