P617Reasons for poor vital sign documentation in electronic health records: a qualitative study

Abstract

Background: There is widespread acceptance that monitoring vital signs with systems such as national early warning scores (NEWS) can reduce the incidence of adverse events such as cardiac arrest in hospital patients. Documentation of vital signs is an essential part of patient monitoring. Previous research has shown that documentation of vital signs in an electronic health record (EHR) was inconsistent and incomplete, and thus a threat to patient safety. This paper focuses on reasons for poor documentation of vital signs in an EHR and makes suggestions for effective digital documentation of vital signs. Purpose(s): The purpose of this study was to examine reasons why documentation of vital signs in an EHR can be incomplete. Method(s): Using a qualitative approach, we examined work processes for measuring, documenting and retrieving vital signs. Data were collected through observations and semi-structured interviews. The setting was a 372-bed county hospital and participants were doctors and nurses working in four separate clinical areas: a cardiology unit; an infection ward; an emergency department; and a surgical ward. The data were collected between August 2014 and January 2015 and analysed using thematic analysis. Result(s): Usability issues in the EHR hindered good documentation of vital signs, e.g., entering and retrieving vital signs was cumbersome and time-consuming. Inadequate visual presentation of vital signs hampered interpretation and decisionmaking. These workflow problems led to the creation of paper workarounds. Routines and practices for measuring vital signs were inconsistent. Conclusion(s): Poor facilities for the documentation of vital signs in EHRs could have a negative impact on patient safety because it reduces the possibility of good record keeping. This leads to limited availability of easily accessible, up-todate information, which is essential for identifying clinical deterioration and, thus, can threaten patient safety. The study suggested possible solutions to usability problems in the EHR. Inconsistent routines were also identified and suggestions were made for how routines and practices could be improved.