title: Nurses' documentation of physiological observations in three acute care settings.
abstract: OBJECTIVE
  To explore nurses' documentation of physiological observations in acute care; emergency department, medical and surgical units.
  
  
  BACKGROUND
  In Australia, physiological observations include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. There is a clear relationship between abnormal physiological observations and adverse events. Nurses have highest level of responsibility for accurate measurement, interpretation and documentation of physiological observations.
  
  
  METHODS
  A descriptive exploratory design was used and the study data were collected using a prospective point prevalence approach between 25 July 2012-22 August 2012.
  
  
  METHODS
  The study was conducted in the emergency department, two 30-bed medical units and one 30-bed surgical unit of a 578 bed public health service in Melbourne, Australia. All adult patients aged ≥18 years present during data collection periods were eligible for inclusion. Patients in the emergency department resuscitation area were excluded. Patient characteristics and physiological observations for the preceding 24 hours in ward patients or eight hours in emergency department patients were collected.
  
  
  RESULTS
  One hundred and seventy-eight patients were included; 38 emergency department patients, 84 medical patients and 56 surgical patients. The median age was 72·5 years and 43·8% were males. The most frequently documented physiological observations were respiratory rate, oxygen saturation, heart rate and systolic blood pressure. The least frequently recorded physiological observations were temperature and conscious state. One or more abnormal physiological parameters was documented in 79·8% (n = 142) patients; evidence of reporting abnormalities was documented in 19·7% of patients (n = 28/142). When controlled for length of stay, physiological observations were more frequently documented in the emergency department.
  
  
  CONCLUSIONS
  There was variability in the number of parameters documented and frequency of physiological observations documented by nurses.
  
  
  CONCLUSIONS
  Physiological abnormalities that do not necessarily fulfil rapid response team activation criteria are common in acute care patients and provide nurses with an opportunity for early recognition of deteriorating patients.
authors.affiliation: Deakin University, Eastern Health - Deakin University Nursing & Midwifery Research Centre, Box Hill, Vic, Australia.|School of Nursing and Midwifery, Burwood, Vic, Australia.|Centre for Quality and Patient Safety Research, Burwood, Vic, Australia.
authors.forename: Julie
authors.identifier: http://orcid.org/0000-0003-3801-2456
authors.initials: J
authors.lastname: Considine
authors.affiliation: Deakin University, Graduate School of Nursing and Midwifery, Burwood, Vic, Australia.|Emergency Department, Northern Health, Epping, Vic, Australia.
authors.forename: Carissa
authors.initials: C
authors.lastname: Trotter
authors.affiliation: Centre for Quality and Patient Safety Research, Burwood, Vic, Australia.|Deakin University, School of Nursing and Midwifery, Burwood, Vic, Australia.
authors.forename: Judy
authors.initials: J
authors.lastname: Currey
mesh_terms: D000328:Adult; D000368:Aged; D001315:Australia; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009736:Nursing Process / Q000592:standards*; D009737:Nursing Records / Q000592:standards*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care
keywords: nursing assessment; patient safety; rapid response team; risk management; vital signs