Agreement between common goals discussed and documented in the ICU

Abstract

Objective: Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. Design: Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system. Measurements: Descriptive statistics and χ2 analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals. Results: One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability (κ) was greater than 0.82. Limitations: Observations in a single ICU setting at a large academic medical center using a commercial EHR. Conclusion: The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care. © 2010 by the American Medical Informatics Association.