Inadequate documentation of asthma management in hospitalized adult patients

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.