"Mind the Gap"—Differences between Documentation and Reality on Intensive Care Units: A Quantitative Observational Study.
Autor: | Raimann, Florian Jürgen, König, Cornelius Johannes, Neef, Vanessa, Flinspach, Armin Niklas |
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Předmět: |
DOCUMENTATION
MEDICAL protocols EMPLOYEES PATIENT compliance CRITICALLY ill PATIENTS HOSPITAL information systems PATIENT safety MEDICAL quality control MEDICATION errors DIGITAL health SCIENTIFIC observation CLONIDINE MEDICAL care RISK management in business QUESTIONNAIRES FISHER exact test QUANTITATIVE research TERTIARY care PATIENT care MIDAZOLAM DESCRIPTIVE statistics ETHICS PROPOFOL ANALGESICS HOSPITAL medical staff PEDIATRICS INTENSIVE care units MEDICAL records ACQUISITION of data NARCOTICS ANALYSIS of variance CATECHOLAMINES ANESTHESIOLOGY COMPARATIVE studies DATA analysis software CRITICAL care medicine CARDIAC surgery COVID-19 pandemic EMPLOYEES' workload MEDICAL care costs COMORBIDITY PSYCHOSOCIAL factors |
Zdroj: | Healthcare (2227-9032); Aug2024, Vol. 12 Issue 15, p1481, 9p |
Abstrakt: | Introduction: Digitalization in medicine is steadily increasing. Complex treatments, scarce personnel resources and a high level of documentation are a constant burden on healthcare systems. The balancing between correct manual documentation in the digital records and limited staff resources is rarely successful. The aim of this study is to evaluate the adherence between documentation and lack of documentation in the treatment of critical care patients. Material and Methods: For the evaluation, data from the hospital information system (HIS) of several intensive care units (ICU) were examined in conjunction with data collected from a checklist. All boluses of sedatives, analgesics and catecholamines were documented paper based across all shifts and all weekdays and compared with corresponding digital data from the HIS (2019–2022) of previous years. Results: 939 complete digital patient records revealed a massive under-documentation of the medication administration compared to that applied according to the checklist. Only 12% of all administered catecholamines, 11% of α |
Databáze: | Complementary Index |
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