{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2022,4,4]],"date-time":"2022-04-04T11:58:13Z","timestamp":1649073493714},"reference-count":0,"publisher":"Akademiai Kiado Zrt.","issue":"21","license":[{"start":{"date-parts":[[2020,5,1]],"date-time":"2020-05-01T00:00:00Z","timestamp":1588291200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["akjournals.com"],"crossmark-restriction":true},"short-container-title":["OH"],"published-print":{"date-parts":[[2020,5]]},"abstract":"Absztrakt: <\/jats:title>\n Bevezet\u00e9s \u00e9s c\u00e9lkit\u0171z\u00e9s:<\/jats:bold><\/jats:italic> A Semmelweis Egyetem\n klinik\u00e1in cerebralis paresis (CP) miatt gondozott gyerekek\n betegdokument\u00e1ci\u00f3j\u00e1nak min\u0151s\u00e9gi ellen\u0151rz\u00e9s\u00e9t v\u00e9gezt\u00fck el.\n M\u00f3dszer:<\/jats:bold><\/jats:italic> Retrospekt\u00edv audit\n vizsg\u00e1latunkban a 2005 \u00e9s 2015 k\u00f6z\u00f6tt sz\u00fcletett, CP-gyan\u00fas gyerekek elektronikus\n k\u00f3rh\u00e1zi rendszerben r\u00f6gz\u00edtett adatait revide\u00e1ltuk, s ennek sor\u00e1n 673, igazoltan\n CP-vel diagnosztiz\u00e1lt esetet regisztr\u00e1ltunk. A fellelhet\u0151 adatok alapj\u00e1n\n elv\u00e9gezt\u00fck az esetek klinikai \u00e9s etiol\u00f3giai besorol\u00e1s\u00e1t, valamint ellen\u0151rizt\u00fck\n ezen adatok el\u00e9rhet\u0151s\u00e9g\u00e9t a betegdokument\u00e1ci\u00f3ban.\n Eredm\u00e9nyek:<\/jats:bold><\/jats:italic> A gyerekek 86%-a rendelkezett\n a klinikai besorol\u00e1sra alkalmas dokument\u00e1ci\u00f3val. A vizsg\u00e1lhat\u00f3 esetek 90,5%-\u00e1ban\n spasticus, 7,8%-\u00e1ban hypoton, 1,2%-\u00e1ban dyskineticus \u00e9s 0,5%-\u00e1ban ataxi\u00e1s CP-t\n \u00edrtak le. Az oszt\u00e1lyozhat\u00f3 spasticus \u00e1llapotok (az \u00f6sszes spasticus eset 98%-a)\n k\u00f6z\u00f6tt 51% tetraparesis\/tetraplegia, 26% diparesis\/diplegia \u00e9s 23%\n hemiparesis\/hemiplegia volt; a marad\u00e9k 2% topol\u00f3giai besorol\u00e1s\u00e1ra nem volt\n elegend\u0151 inform\u00e1ci\u00f3 a dokument\u00e1ci\u00f3ban. Az esetek 82%-\u00e1ban volt meghat\u00e1rozhat\u00f3 a\n s\u00falyoss\u00e1g a Gross Motor Function Classification System sk\u00e1la szerint, 43%-ban\n I\u2013II., 28%-ban III., 29%-ban IV\u2013V. fok\u00fa mozg\u00e1skorl\u00e1tozotts\u00e1got v\u00e9lem\u00e9nyeztek. A\n sz\u00fclet\u00e9si anamn\u00e9zisre vonatkoz\u00f3 adatokat az esetek 89%-\u00e1ban tal\u00e1ltunk.\n Korasz\u00fcl\u00f6tts\u00e9g az esetek 55%-\u00e1ban, perinatalis asphyxia vagy hypoxi\u00e1s-ischaemi\u00e1s\n encephalopathia 31%-ban, agykamrai vagy agy\u00e1llom\u00e1nyi v\u00e9rz\u00e9s 27%-ban,\n ikerterhess\u00e9g 19%-ban, m\u00e9hen bel\u00fcli sorvad\u00e1s 18%-ban,\n intrauterin\/perinatalis\/csecsem\u0151kori infekci\u00f3 15%-ban, fejl\u0151d\u00e9si rendelleness\u00e9g\n 12%-ban, in vitro<\/jats:italic> fertilisatio 5%-ban, stroke 3%-ban, CP-vel\n asszoci\u00e1lhat\u00f3 genetikai mut\u00e1ci\u00f3 pedig 3%-ban szerepelt az anamn\u00e9zisben. A CP\n rizik\u00f3t\u00e9nyez\u0151inek szempontj\u00e1b\u00f3l negat\u00edv anamn\u00e9zist 16%-ban \u00edrtak le.\n K\u00f6vetkeztet\u00e9s:<\/jats:bold><\/jats:italic> Audit vizsg\u00e1latunk alapj\u00e1n\n a CP klinikai le\u00edr\u00e1sa egys\u00e9ges krit\u00e9riumok szerint t\u00f6rt\u00e9nt, hi\u00e1nyoss\u00e1gokat a\n klinikai besorol\u00e1s \u00e9s az anamnesztikus adatok r\u00f6gz\u00edt\u00e9se ter\u00e9n \u00e9szlelt\u00fcnk. Az\n adatgy\u0171jt\u00e9s egys\u00e9ges\u00edt\u00e9se c\u00e9lj\u00e1b\u00f3l javaslatot tesz\u00fcnk az \u00e9rintett betegek\n gondoz\u00e1sa sor\u00e1n regisztr\u00e1land\u00f3 dokument\u00e1ci\u00f3s standardra, mely az egys\u00e9ges\n betegdokument\u00e1ci\u00f3 \u00e9s egy j\u00f6v\u0151beli hazai CP-regiszter alapfelt\u00e9tele. Orv Hetil.\n 2020; 161(21): 873\u2013880.<\/jats:p>","DOI":"10.1556\/650.2020.31722","type":"journal-article","created":{"date-parts":[[2020,5,19]],"date-time":"2020-05-19T09:21:25Z","timestamp":1589880085000},"page":"873-880","update-policy":"http:\/\/dx.doi.org\/10.1556\/policypage.crossmark.crossref.1","source":"Crossref","is-referenced-by-count":0,"title":["A cerebralis paresis el\u0151fordul\u00e1sa \u00e9s a betegdokument\u00e1ci\u00f3 min\u0151s\u00e9gi vizsg\u00e1lata a Semmelweis Egyetem klinik\u00e1in"],"prefix":"10.1556","volume":"161","author":[{"given":"Hajnalka","family":"Barta","sequence":"first","affiliation":[{"name":"1 \u00c1ltal\u00e1nos Orvostudom\u00e1nyi Kar, I. 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