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Health Informatics J. 2016 Mar;22(1):21-33. doi: 10.1177/1460458214530136. Epub 2014 Apr 29.

Recording signs of deterioration in acute patients: The documentation of vital signs within electronic health records in patients who suffered in-hospital cardiac arrest.

Author information

1
University of Sheffield, UK; Linnaeus University, Sweden jean.stevenson.agren@lnu.se.
2
Kalmar County Hospital, Sweden.
3
Linnaeus University, Sweden.
4
University of Sheffield, UK.

Abstract

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 VitalPACâ„¢ 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.

KEYWORDS:

clinical decision-making; electronic health records; in-hospital cardiac arrest; track and trigger systems

PMID:
24782478
DOI:
10.1177/1460458214530136
[Indexed for MEDLINE]
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