Victoria Y Vivtcharenko1, Sonali Ramesh2, Kimberly C Dukes3,4, Hardeep Singh5, Loreen A Herwaldt4, Heather Schacht Reisinger3,4,6, Christina L Cifra7. 1. University of Iowa Carver College of Medicine, Iowa City, IA. 2. Department of Pediatrics, BronxCare Health System, New York, NY. 3. Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA. 4. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA. 5. Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX. 6. Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA. 7. Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA.
Abstract
OBJECTIVES: Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission. DESIGN: Retrospective mixed methods study describing diagnosis documentation in electronic health records. SETTING: Academic tertiary referral PICU. PATIENTS: Children 0-17 years old admitted nonelectively to a single PICU over 1 year. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty. CONCLUSIONS: In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
OBJECTIVES: Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission. DESIGN: Retrospective mixed methods study describing diagnosis documentation in electronic health records. SETTING: Academic tertiary referral PICU. PATIENTS: Children 0-17 years old admitted nonelectively to a single PICU over 1 year. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty. CONCLUSIONS: In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
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