Agreement between common goals discussed and documented in the ICU.
OBJECTIVE
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.


METHODS
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.


METHODS
Descriptive statistics and χ(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 (κ) was greater than 0.82.


CONCLUSIONS
Observations in a single ICU setting at a large academic medical center using a commercial EHR.


CONCLUSIONS
The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.
Department of Biomedical Informatics, Columbia University, New York, New York, USA. sarah.collins@dbmi.columbia.edu
Sarah A
SA
Collins
Suzanne
S
Bakken
David K
DK
Vawdrey
Enrico
E
Coiera
Leanne M
LM
Currie
D003266:Continuity of Patient Care; D004282:Documentation; D057286:Electronic Health Records; D006040:Goals; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D007400:Interprofessional Relations; D008137:Longitudinal Studies; D009519:New York City; D010347:Patient Care Planning; D010348:Patient Care Team / Q000458:organization & administration; D012121:Respiration, Artificial