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Recording signs of deterioration in acute patients: The documentation of vital signs within electronic health records in patients who suffered in-hospital cardiac arrest
Linnéuniversitetet, Fakulteten för Hälso- och livsvetenskap (FHL), Institutionen för hälso- och vårdvetenskap (HV). University of Sheffield, UK. (iCARE)ORCID-id: 0000-0002-4626-3979
Kalmar County Hospital, Sweden. (iCARE)
Linnéuniversitetet, Fakulteten för Hälso- och livsvetenskap (FHL), Institutionen för hälso- och vårdvetenskap (HV). (iCARE)
Linnéuniversitetet, Fakulteten för Hälso- och livsvetenskap (FHL), Institutionen för medicin och optometri (MEO). (eHälsoinstitutet ; eHealth Institute ; iCARE ; DISA ; DISA-IDP)ORCID-id: 0000-0002-4295-7201
Vise andre og tillknytning
2016 (engelsk)Inngår i: Health Informatics Journal, ISSN 1460-4582, E-ISSN 1741-2811, Vol. 22, nr 1, s. 21-33Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

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 VitalPACTM 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. 

sted, utgiver, år, opplag, sider
Sage Publications, 2016. Vol. 22, nr 1, s. 21-33
Emneord [en]
vital signs, electronic health records, documentation
HSV kategori
Forskningsprogram
Hälsovetenskap, Hälsoinformatik
Identifikatorer
URN: urn:nbn:se:lnu:diva-46355DOI: 10.1177/1460458214530136ISI: 000368726900002PubMedID: 24782478Scopus ID: 2-s2.0-84955322777OAI: oai:DiVA.org:lnu-46355DiVA, id: diva2:854459
Tilgjengelig fra: 2015-09-16 Laget: 2015-09-16 Sist oppdatert: 2019-02-18bibliografisk kontrollert

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Stevenson-Ågren, JeanIsraelsson, JohanNilsson, GunillaPetersson, Göran

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