Recording signs of deterioration in acute patients The documentation of vital signs within electronic healthrecords in patients who suffered inhospital cardiac arrest

• Published in: Health informatics journal Vol. 22; no. 1; p. 21
• Main Authors: Stevenson, Jean E, Israelsson, Johan, Nilsson, Gunilla C, Petersson, Göran I, Bath, Peter A
• Format: Journal Article
• Language: English
• Published: 2016
• Subjects: clinical decision-making; electronic health records; in-hospital cardiac arrest; track and trigger systems
• ISSN: 1460-4582; 1741-2811
• DOI: 10.1177/1460458214530136

Vital sign documentation is crucial to detecting patient deterioration. Little is known about the documentation of vital signs in electronic health records. This study aimed to examine documentation of vital signs in electronic health records. We examined the vital signs documented in the electronic health records of patients who had suffered an in-hospital cardiac arrest and on whom cardiopulmonary resuscitation was attempted between 2007 and 2011 (n = 228), in a 372-bed district general hospital. We assessed the completeness of vital sign data compared to VitalPAC™ Early Warning Score and the location of vital signs within the electronic health records. There was a noticeable lack of completeness of vital signs. Vital signs were fragmented through various sections of the electronic health records. The study identified serious shortfalls in the representation of vital signs in the electronic health records, with consequential threats to patient safety.