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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
Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. University of Sheffield, UK.ORCID iD: 0000-0002-4626-3979
Kalmar County Hospital, Sweden.
Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. (eHälsoinstitutet ; eHealth Institute)ORCID iD: 0000-0002-4295-7201
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2016 (English)In: Health Informatics Journal, ISSN 1460-4582, E-ISSN 1741-2811, Vol. 22, no 1, p. 21-33Article in journal (Refereed) 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. 

Place, publisher, year, edition, pages
Sage Publications, 2016. Vol. 22, no 1, p. 21-33
Keywords [en]
vital signs, electronic health records, documentation
National Category
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health and Caring Sciences, Health Informatics
Identifiers
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
Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2018-05-18Bibliographically approved

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Stevenson-Ågren, JeanIsraelsson, JohanNilsson, GunillaPetersson, Göran

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Stevenson-Ågren, JeanIsraelsson, JohanNilsson, GunillaPetersson, Göran
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CiteExportLink to record
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Citation style
  • apa
  • harvard1
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  • vancouver
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Language
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More languages
Output format
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