Date

12-2014

Document Type

Capstone

Degree Name

M.B.I.

Department

Department of Medical Informatics and Clinical Epidemiology

Institution

Oregon Health & Science University

Abstract

Introduction:

Clinical documentation is an essential aspect of the patient-clinician encounter and serves many purposes. With the increasing use of the electronic health record, computerized clinical documentation will soon become ubiquitous. It is one of the means of communication between healthcare providers. Ensuring good quality documentation is crucial to good patient care. The intensive care unit is a complex, dynamic environment and large amounts of data are generated daily for each patient.

Good documentation becomes challenging in this situation. The quality of documentation in the intensive care unit has not been studied.

Objective:

The overall quality of computerized clinical documentation in a pediatric intensive care unit was evaluated; documents were also rated on the basis of individual components of quality. Certain factors that may affect the quality of the notes were also studied.

Methods:

A retrospective chart review was performed and 100 history and physical and progress notes were rated using the PDQI-9 tool. Data regarding the author of the notes, time of starting and completing the note in relation to the time of service, length of hospital and intensive care unit stay prior to the day of service, number of notes written in the intensive care unit that day, the day of the week that the service was provided, and severity of illness of the patient were collected.

Results:

The overall quality of the notes was good with a mean total PDQI-9 score of 39 (maximum score possible is 45). Almost all notes were rated highly (score of 4 or 5 out of a maximum of 5) on succinct (99%) and a large majority of them were rated highly on comprehensible (93%), up-to-date (92%), accurate (92%), internally consistent (92%), synthesized (81%) and organized (80%). About two-third of the notes were rated highly on useful and 37% on thorough. There was a statistically significant correlation between the quality of the notes and the severity of illness and number of notes written on that day. As the number of notes increased, the quality of the notes deteriorated if they were written by residents or fellows, but not if they were written by nurse practitioners or attending physicians.

Conclusions:

Despite the complexities of the intensive care unit and the limitations of a commercial EHR, clinicians could capture information about the patient, synthesize it and generate good quality notes. The quality of notes declined with an increase in the number of patients or severity of illness.

Identifier

doi:10.6083/M4WM1C4T

School

School of Medicine

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