Jean E Stevenson1,2, Johan Israelsson3,4,5, Goran Petersson2, Peter A Bath1. 1. Information School, Sheffield University, Sheffield, South Yorkshire, UK. 2. eHealth Institute, Linnaeus University, Kalmar, Sweden. 3. Division of Cardiology, Department of Internal Medicine, Kalmar County Hospital, Kalmar, Sweden. 4. Kalmar Maritime Academy, Linnaeus University, Kalmar, Sweden. 5. Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden.
Abstract
AIMS AND OBJECTIVES: To investigate reasons for inadequate documentation of vital signs in an electronic health record. BACKGROUND: Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent. DESIGN: Qualitative study. METHODS: Qualitative study. Data were collected by observing (68 hr) and interviewing nurses (n = 11) and doctors (n = 3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital. RESULTS: We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients' vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper "workarounds." CONCLUSIONS: This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs. RELEVANCE TO CLINICAL PRACTICE: Patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.
AIMS AND OBJECTIVES: To investigate reasons for inadequate documentation of vital signs in an electronic health record. BACKGROUND: Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent. DESIGN: Qualitative study. METHODS: Qualitative study. Data were collected by observing (68 hr) and interviewing nurses (n = 11) and doctors (n = 3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital. RESULTS: We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients' vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper "workarounds." CONCLUSIONS: This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs. RELEVANCE TO CLINICAL PRACTICE: Patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.
Authors: Benjamin J Duncan; Lu Zheng; Stephanie K Furniss; Andrew J Solomon; Brad N Doebbeling; Grando Grando; Matthew M Burton; Karl A Poterack; Timothy A Miksch; Richard A Helmers; David R Kaufman Journal: AMIA Annu Symp Proc Date: 2018-12-05
Authors: Chanu Rhee; Zilu Zhang; Sameer S Kadri; David J Murphy; Greg S Martin; Elizabeth Overton; Christopher W Seymour; Derek C Angus; Raymund Dantes; Lauren Epstein; David Fram; Richard Schaaf; Rui Wang; Michael Klompas Journal: Crit Care Med Date: 2019-03 Impact factor: 7.598
Authors: Heather E Hsu; Francisca Abanyie; Michael S D Agus; Fran Balamuth; Patrick W Brady; Richard J Brilli; Joseph A Carcillo; Raymund Dantes; Lauren Epstein; Anthony E Fiore; Jeffrey S Gerber; Runa H Gokhale; Benny L Joyner; Niranjan Kissoon; Michael Klompas; Grace M Lee; Charles G Macias; Karen M Puopolo; Carmen D Sulton; Scott L Weiss; Chanu Rhee Journal: Pediatrics Date: 2019-12 Impact factor: 7.124