J Am Med Inform Assoc - Agreement between common goals discussed and documented in the ICU.


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JECTIVE: Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR.DESIGN: Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system.MEASUREMENTS: Descriptive statistics and (2) analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals.RESULTS: One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability () was greater than 0.82.LIMITATIONS: Observations in a single ICU setting at a large academic medical center using a commercial EHR.CONCLUSION: The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.

Resumo Limpo

jectiv meaning use electron health record ehr depend accur clinic document document common goal intens care unit icu sedat ventil manag plan may increas collabor decreas patient length stay studi analyz degre goal state present ehrdesign descript correl studi common goal verbal state daili icu interdisciplinari round compar presenc goal action relat goal document ehr subsequ h patient day studi set neurovascular icu fulli implement electron nurs physician document systemmeasur descript statist analys use assess differ ehr document state goal goalrel action intercod reliabl perform state goalsresult onequart state goal document ehr goal document action relat goal less like document attend physician note contain state ventil wean goal sedat wean goal addit sedat goal part structur nurs document intercod reliabl greater limit observ singl icu set larg academ medic center use commerci ehrconclus current document tool avail ehr may suffici captur common goal icu patient care

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