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Factors influencing...
Factors influencing the quality of vital signs data in electronic health records : a qualitative study
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- Stevenson-Ågren, Jean (författare)
- Linnéuniversitetet,Institutionen för medicin och optometri (MEO),University of Sheffield, UK,eHälsoinstitutet;eHealth Institute;Centre for Health Information Management Research (CHIMR)
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- Israelsson, Johan (författare)
- Linköpings universitet,Linnéuniversitetet,Sjöfartshögskolan (SJÖ),Kalmar County Hospital, Sweden;Linköping University, Sweden,Avdelningen för omvårdnad,Medicinska fakulteten,Division of Cardiology, Department of Internal Medicine, Kalmar County Hospital, Kalmar, Sweden; Kalmar Maritime Academy, Linnaeus University, Kalmar, Sweden
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- Petersson, Göran (författare)
- Linnéuniversitetet,Institutionen för medicin och optometri (MEO),eHälsoinstitutet;eHealth Institute;DISA-IDP;DISA,eHealth Institute, Linnaeus University, Kalmar, Sweden
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- Bath, Peter (författare)
- Information School, Sheffield University, Sheffield, South Yorkshire, UK,Centre for Health Information Management Research (CHIMR)
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- Stevenson, Jean E (författare)
- Information School, Sheffield University, Sheffield, South Yorkshire, UK; eHealth Institute, Linnaeus University, Kalmar, Sweden
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(creator_code:org_t)
- 2018-01-08
- 2018
- Engelska.
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Ingår i: Journal of Clinical Nursing. - New Jersey : John Wiley & Sons. - 0962-1067 .- 1365-2702. ; 27:5-6, s. 1276-1286
- Relaterad länk:
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http://eprints.white...
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https://urn.kb.se/re...
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https://doi.org/10.1...
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https://urn.kb.se/re...
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Abstract
Ämnesord
Stäng
- Aims and objectivesTo investigate reasons for inadequate documentation of vital signs in an electronic health record.BackgroundMonitoring 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.DesignQualitative study.MethodsQualitative 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.ResultsWe 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.”ConclusionsThis 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 practicePatient 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.
Ämnesord
- MEDICIN OCH HÄLSOVETENSKAP -- Annan medicin och hälsovetenskap -- Övrig annan medicin och hälsovetenskap (hsv//swe)
- MEDICAL AND HEALTH SCIENCES -- Other Medical and Health Sciences -- Other Medical and Health Sciences not elsewhere specified (hsv//eng)
- MEDICIN OCH HÄLSOVETENSKAP -- Hälsovetenskap -- Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi (hsv//swe)
- MEDICAL AND HEALTH SCIENCES -- Health Sciences -- Health Care Service and Management, Health Policy and Services and Health Economy (hsv//eng)
Nyckelord
- Vital signs
- patient safety
- electronic health records
- Health Informatics
- Hälsoinformatik
Publikations- och innehållstyp
- ref (ämneskategori)
- art (ämneskategori)
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