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Factors influencing the quality of vital signs data in electronic health records: a qualitative study
Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. University of Sheffield. (Centre for Health Information Management Research (CHIMR))ORCID iD: 0000-0002-4626-3979
Kalmar County Hospital, Sweden.
Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry.
University of Sheffield, England. (Centre for Health Information Management Research (CHIMR))
2017 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 6, no 1, article id 14794412Article in journal (Refereed) Published
Abstract [en]

Abstract

Aims and objectives

To investigate reasons for inadequate documentation of vital signs in an electronic health record.

Background

Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent.

Design

Qualitative study.

Methods

Qualitative study. Data were collected by observing (68 hr) and interviewing nurses (n = 11) and doctors (n = 3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital.

Results

We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients’ vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper “workarounds.”

Conclusions

This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs.

Relevance to clinical practice

Patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.

Place, publisher, year, edition, pages
New Jersey: John Wiley & Sons, 2017. Vol. 6, no 1, article id 14794412
Keyword [en]
Vital signs, patient safety, electronic health records
National Category
Medical and Health Sciences
Research subject
Health and Caring Sciences, Health Informatics
Identifiers
URN: urn:nbn:se:lnu:diva-70319DOI: 10.1111/jocn.14174OAI: oai:DiVA.org:lnu-70319DiVA: diva2:1179257
Available from: 2018-01-31 Created: 2018-01-31 Last updated: 2018-01-31

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