Documentation of vital signs 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.

Subject headings

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)

Keyword

Electronic records

Vital signs

Workarounds

Patient safety

Health Informatics

Hälsoinformatik

Publication and Content Type

ref (subject category)

kon (subject category)