• Louise Arntsberg, Sara Fernberg, Ann-Sofie Berger, Katarina Hedin, and Anna Moberg.
• Hälsan 2 Primary Health Care Centre, Jönköping, Sweden.
• Scand J Prim Health Care. 2024 Jun 1; 42 (2): 338346338-346.

ObjectiveTo compare management and documentation of vital signs, symptoms and infection severity in pneumonia patients seeking primary care and emergency care without referral.DesignMedical record review of vital signs, examination findings and severity of pneumonia.SettingPrimary and emergency care.SubjectsTwo hundred and forty patients diagnosed with pneumonia.Main Outcome MeasuresVital signs, examination findings and severity of pneumonia. Assessments of pneumonia severity according to the reviewers, the traffic light score and CRB-65.ResultsRespiratory rate, blood pressure, heart rate and oxygen saturation were less often documented in primary care (p < .001). Chest X-ray was performed in 5% of primary care patients vs. 88% of emergency care patients (p < .01). Primary care patients had longer symptom duration, higher oxygen saturation and lower respiratory rate. In total, the reviewers assessed 63% of all pneumonias as mild and 9% as severe. The traffic light scoring model identified 11 patients (9%) in primary care and 53 patients (44%) in emergency care at high risk of severe infection.ConclusionsVital signs were documented less often in primary care than in emergency care. Patients in primary care appear to have a less severe pneumonia, indicating attendance to the correct care level. The traffic light scoring model identified more patients at risk of severe infection than CRB-65, where the parameters were documented to a limited extent.

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