The effect of point-of-care personal digital assistant use on resident documentation discrepancies

We recently found documentation discrepancies in 60% of resident daily-progress notes with respect to patient weight, medications, or vascular lines. To what extent information systems can decrease such discrepancies is unknown.

To determine whether a point-of-care personal digital assistant (PDA)-based patient record and charting system could reduce the number of resident progress-note documentation discrepancies in a neonatal intensive care unit (NICU).

We conducted a before-and-after trial in an academic NICU. Our intervention was a PDA-based patient record and charting system used by all NICU resident physicians over the study period. We analyzed all resident daily-progress notes from 40 randomly selected days over 4 months in both the baseline and intervention periods. Using predefined reference standards, we determined the accuracy of recorded information for patient weights, medications, and vascular lines. Logistic and Poisson regression were used in analyses to control for potential confounding factors.

A total of 339 progress notes in the baseline period and 432 progress notes in the intervention period were reviewed. When controlling for covariates in the regression, there were significantly fewer documentation discrepancies of patient weights in notes written by using the PDA system (14.4%-4.4% of notes; odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.15-0.56). When using the PDA system, there were no significant changes in the numbers of notes with documentation discrepancies of medications (27.7%-17.1% of notes; OR: 0.63; 95% CI: 0.35-1.13) or vascular lines (33.6%-36.1% of notes; OR: 1.11; 95% CI: 0.66-1.87).

The use of our PDA-based point-of-care patient record and charting system showed a modest benefit in reducing the number of documentation discrepancies in resident daily-progress notes. Further study of PDAs in information systems is warranted before they are widely adopted.