Health Informatics J - Recording signs of deterioration in acute patients: The documentation of vital signs within electronic health records in patients who suffered in-hospital cardiac arrest.

Tópicos

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Resumo

Vital sign documentation is crucial to detecting patient deterioration. Little is known about the documentation of vital signs in electronic health records. This study aimed to examine documentation of vital signs in electronic health records. We examined the vital signs documented in the electronic health records of patients who had suffered an in-hospital cardiac arrest and on whom cardiopulmonary resuscitation was attempted between 2007 and 2011 (n = 228), in a 372-bed district general hospital. We assessed the completeness of vital sign data compared to VitalPAC? Early Warning Score and the location of vital signs within the electronic health records. There was a noticeable lack of completeness of vital signs. Vital signs were fragmented through various sections of the electronic health records. The study identified serious shortfalls in the representation of vital signs in the electronic health records, with consequential threats to patient safety.

Resumo Limpo

vital sign document crucial detect patient deterior littl known document vital sign electron health record studi aim examin document vital sign electron health record examin vital sign document electron health record patient suffer inhospit cardiac arrest cardiopulmonari resuscit attempt n bed district general hospit assess complet vital sign data compar vitalpac earli warn score locat vital sign within electron health record notic lack complet vital sign vital sign fragment various section electron health record studi identifi serious shortfal represent vital sign electron health record consequenti threat patient safeti

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