Understanding Factors Contributing to Inappropriate Critical Care: A Mixed-Methods Analysis of Medical Record Documentation

Abstract Objective The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. Materials and Methods In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. Results Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. Discussion Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. Conclusion Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

Download Full-text

A mixed-methods study of pharmacy instructors' early experiences with a teaching electronic medical record

Currents in Pharmacy Teaching and Learning ◽

10.1016/j.cptl.2021.06.036 ◽

2021 ◽

Author(s):

Omolola A. Adeoye-Olatunde ◽

Olga O. Vlashyn ◽

Kimberly S. Illingworth Plake ◽

Jamie L. Woodyard ◽

Zachary A. Weber ◽

...

Keyword(s):

Mixed Methods ◽

Medical Record ◽

Electronic Medical Record ◽

Mixed Methods Study ◽

Early Experiences

Download Full-text

"Concordance between comorbidity data from patient self-report interviews and medical record documentation"

BMC Health Services Research ◽

10.1186/1472-6963-8-85 ◽

2008 ◽

Vol 8 (1) ◽

Cited By ~ 62

Author(s):

William Corser ◽

Alla Sikorskii ◽

Ade Olomu ◽

Manfred Stommel ◽

Camille Proden ◽

...

Keyword(s):

Medical Record ◽

Self Report ◽

Medical Record Documentation

Download Full-text

Medical Record Documentation of Seizures

Pediatrics in Review ◽

10.1542/pir.13.2.76 ◽

1992 ◽

Vol 13 (2) ◽

pp. 76-77

Keyword(s):

Medical Record ◽

Chief Complaint ◽

Total Loss ◽

Loss Of Consciousness ◽

Pertinent Data ◽

Sample Record ◽

Medical Record Documentation

This sample record is meant to demonstrate comprehensive recording of pertinent data. Actual records will vary in format; many will be written in a more abbreviated style. Name: Sharon DiStefano1 Date of birth: December 8, 19832 Drug allergies: None; cramps from erythromycin3 Immunizations: Fully immunized4 Thursday, February 6, 1992 Telephone Teacher called parents — Sharon "suddenly gets a blank look" for brief periods. Has done this several times. Parents will get further information from teacher, watch carefully over weekend, bring in for visit next week. Tuesday, February 11, 1992 CHIEF COMPLAINT: "We think she's having spells." PRESENT ILLNESS: (See letter from teacher). He has noted over the last week, on 5 or 6 occasions, that Sharon will develop "blank stare" suddenly. When talked to, will not respond at first but will after several repetitions. Once did this in the middle of talking; paused noticeably for a number of seconds, then resumed talking. Eyes always stay open; blinking noted; no total loss of consciousness. No jerking, twitching, slumping, drooling, incontinence. Seems normal afterwards; not aware of any lapse. Over the weekend parents saw similar spells: three times at meals, twice when watching television, once after she had been running around backyard and had just sat down. "Like a shade was drawn behind her eyes."

Download Full-text

Sa1046 Improving Medical Record Documentation of Clinical Encounters in Inflammatory Bowel Disease (IBD) Patients: A Review of Current Practice

Gastroenterology ◽

10.1016/s0016-5085(15)30687-9 ◽

2015 ◽

Vol 148 (4) ◽

pp. S-206

Author(s):

Ashraf A. Almashhrawi ◽

Fazia A. Mir ◽

Amin Mahdi ◽

Anjana Sathyamurthy ◽

Richard Madsen ◽

...

Keyword(s):

Inflammatory Bowel Disease ◽

Medical Record ◽

Bowel Disease ◽

Current Practice ◽

Clinical Encounters ◽

Inflammatory Bowel ◽

Medical Record Documentation

Download Full-text

A pilot study of the impact of an educational intervention aimed at improving medical record documentation

The Journal of the Royal College of Physicians of Edinburgh ◽

10.4997/jrcpe.2013.106 ◽

2013 ◽

Vol 43 (1) ◽

pp. 29-34 ◽

Cited By ~ 12

Author(s):

M Farzandipour ◽

Z Meidani ◽

F Rangraz Jeddi ◽

H Gilasi ◽

L Shokrizadeh Arani ◽

...

Keyword(s):

Pilot Study ◽

Medical Record ◽

Educational Intervention ◽

The Impact ◽

Medical Record Documentation

Download Full-text

QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

Medical Technologies Journal ◽

10.26415/2572-004x-vol1iss4p98-99 ◽

2017 ◽

Vol 1 (4) ◽

pp. 98-99

Author(s):

Zahra Mazloum khorasani ◽

Mahmood Tara ◽

Kobra Etminani ◽

Zohre Moosavi ◽

Zahra Ebnehoseini

Keyword(s):

Medical Record ◽

Medical Records ◽

Qualitative Evaluation ◽

Cross Sectional Study ◽

Diabetic Patients ◽

Cross Sectional ◽

Accurate Treatment ◽

Diabetes Center ◽

Data Elements ◽

Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients. Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

Download Full-text

MEDICAL RECORD DOCUMENTATION OF ACUTE GASTROENTERITIS

Pediatrics in Review ◽

10.1542/pir.12.12.374 ◽

1991 ◽

Vol 12 (12) ◽

pp. 374-374

Keyword(s):

Medical Record ◽

Electrolyte Solution ◽

Acute Gastroenteritis ◽

Birth Date ◽

Loose Stool ◽

Late Afternoon ◽

Full Strength ◽

Medical Record Documentation

Name: Matthew Pringle1 Birth date: July 15, 19902 Drug allergies: None known3 Thursday, February 14, 1991. Telephone 11:00 AM. Matt vomited x2 since getting up—1 loose stool. Alert, wet diapers twice today. No fever. Mom to give 1-2 oz of commercial maintenance electrolyte solution (40-50 mEq/L of sodium) every 20-30 min. Call back late afternoon. W.R., MD 4:00 PM. No more vomiting. Kept 12 oz of electrolyte solution. Very wet diaper now. 1 loose stool. Regularly on soy formula. Mom to give 2-3 bottles of diluted soy, then full-strength. Call tomorrow morning—sooner if diarrhea worsens, has repeated vomiting, or starts to look sicker. W.R., MD

Download Full-text