title: Is asthma documentation improved by computer-facilitated data entry?
abstract: The documentation of acute asthma in written medical records was compared with data entered into a Computer-Assisted Triage System (CATS) in 104 children who presented to the emergency department and subsequently admitted to the Royal Alexandra Hospital for Children, Sydney. A total of 65 items in 5 categories were analysed and satisfactory documentation was defined as the recording of a specific item in more than 80% of records (written or electronic). Satisfactory documentation was observed for all 6 items in visit details and 9 out of 10 items in triage details for both recording systems. Nursing observations were better documented in the medical record than in CATS (87 vs 25%; kappa = 0.63). Documentation of medical details was also worse in CATS (75 vs 25%; kappa = 0.24) and the documentation of asthma severity was poor in both systems (31 vs 0%; kappa = 0.31). Attempts to improve asthma documentation through the development of a computerized medical record have highlighted further barriers to documentation.
authors.affiliation: Institute of Child and Mother Health, Dhaka, Bangladesh.
authors.forename: A
authors.initials: A
authors.lastname: Kabir
authors.forename: R
authors.initials: R
authors.lastname: Hanson
authors.forename: C M
authors.initials: CM
authors.lastname: Mellis
authors.forename: P P
authors.initials: PP
authors.lastname: van Asperen
mesh_terms: D001249:Asthma; D002648:Child; D002675:Child, Preschool; D004282:Documentation / Q000379:methods* / Q000592:standards; D001330:Electronic Data Processing / Q000592:standards*; D005260:Female; D006776:Hospitals, Pediatric / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D008297:Male; D008499:Medical Records / Q000592:standards*; D009517:New South Wales; D010343:Patient Admission; D014218:Triage