Recording signs of deterioration in acute patients: The documentation of vital signs within electronic health records in patients who suffered in-hospital cardiac arrest.
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.
University of Sheffield, UK; Linnaeus University, Sweden jean.stevenson.agren@lnu.se.
Jean E
JE
Stevenson
Kalmar County Hospital, Sweden.
Johan
J
Israelsson
Linnaeus University, Sweden.
Gunilla C
GC
Nilsson
Linnaeus University, Sweden.
Göran I
GI
Petersson
University of Sheffield, UK.
Peter A
PA
Bath
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D006323:Heart Arrest / Q000175:diagnosis* / Q000451:nursing; D017052:Hospital Mortality; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D055986:Vital Signs
clinical decision-making; electronic health records; in-hospital cardiac arrest; track and trigger systems