Vital sign documentation in electronic records : the development of workarounds

• Workarounds are commonplace in health care settings. An increase in the use of electronic health records (EHR) has led to an escalation of workarounds as health care professionals cope with systems which are inadequate for their needs. Closely related to this, the documentation of vital signs in EHR has been problematic. The accuracy and completeness of vital sign documentation has a direct impact on the recognition of deterioration in a patient’s condition. We examined work flow processes to identify workarounds related to vital signs in a 372-bed hospital in Sweden. In three clinical areas a qualitative study was performed with data collected during observations and interviews and analysed through thematic content analysis. We identified paper workarounds in the form of hand-written notes and a total of eight pre-printed paper observation charts. Our results suggested that nurses created workarounds to allow a smooth workflow and to ensure patients safety.

Ämnesord

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)

NATURVETENSKAP  -- Data- och informationsvetenskap -- Systemvetenskap, informationssystem och informatik (hsv//swe)

NATURAL SCIENCES  -- Computer and Information Sciences -- Information Systems (hsv//eng)

Nyckelord

electronic health records

healthcare professionals

patient safety

vital signs

workarounds

Health Informatics

Hälsoinformatik

Publikations- och innehållstyp

ref (ämneskategori)

art (ämneskategori)