liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Factors influencing the quality of vital sign data in electronic health records: A qualitative study
Information School, Sheffield University, Sheffield, South Yorkshire, UK.2eHealth Institute, Linnaeus University, Kalmar, Sweden..
Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Division of Cardiology, Department of Internal Medicine, Kalmar County Hospital, Kalmar, Sweden.4Kalmar Maritime Academy, Linnaeus University, Kalmar, Sweden..
eHealth Institute, Linnaeus University, Kalmar, Sweden.
Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.
2018 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 27, no 5-6, p. 1276-1286Article in journal (Refereed) Published
Abstract [en]

AIMS AND OBJECTIVES: To investigate reasons for inadequate documentation of vital signs in an electronic health record.

BACKGROUND: Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent.

DESIGN: Qualitative study.

METHODS: Qualitative study. Data were collected by observing (68 hr) and interviewing nurses (n = 11) and doctors (n = 3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital.

RESULTS: We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients' vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper "workarounds."

CONCLUSIONS: This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs.

RELEVANCE TO CLINICAL PRACTICE: Patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.

Place, publisher, year, edition, pages
Wiley-Blackwell Publishing Inc., 2018. Vol. 27, no 5-6, p. 1276-1286
Keyword [en]
electronic health records, patient safety, qualitative study, vital signs
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-146120DOI: 10.1111/jocn.14174PubMedID: 29149483Scopus ID: 2-s2.0-85044258923OAI: oai:DiVA.org:liu-146120DiVA, id: diva2:1193974
Available from: 2018-03-28 Created: 2018-03-28 Last updated: 2018-04-19Bibliographically approved

Open Access in DiVA

No full text in DiVA

Other links

Publisher's full textPubMedScopus

Authority records BETA

Israelsson, Johan

Search in DiVA

By author/editor
Israelsson, JohanBath, Peter A
By organisation
Division of Nursing ScienceFaculty of Medicine and Health Sciences
In the same journal
Journal of Clinical Nursing
Health Care Service and Management, Health Policy and Services and Health Economy

Search outside of DiVA

GoogleGoogle Scholar

doi
pubmed
urn-nbn

Altmetric score

doi
pubmed
urn-nbn
Total: 45 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf