Related Experiment Video
Updated: Jun 6, 2026
10:38
Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
Published on: January 16, 2019
Agreement between common goals discussed and documented in the ICU
Sarah A Collins1, Suzanne Bakken, David K Vawdrey
1Department of Biomedical Informatics, Columbia University, New York, New York, USA. sarah.collins@dbmi.columbia.edu
Journal of the American Medical Informatics Association : JAMIA
|November 30, 2010
Summary
Electronic health records (EHRs) often fail to document critical care goals, impacting patient care. Sedation and ventilator management plans require better EHR integration for improved collaboration and reduced length of stay.
Area of Science:
- Critical Care Medicine
- Health Informatics
- Clinical Documentation Improvement
Background:
- Effective use of Electronic Health Records (EHRs) hinges on accurate clinical documentation.
- Documenting common goals in the Intensive Care Unit (ICU), such as sedation and ventilator management, can enhance collaboration and potentially shorten patient length of stay.
Purpose of the Study:
- To analyze the extent to which goals verbally stated during ICU rounds are subsequently documented within the EHR.
- To compare the documentation of stated goals and related actions in the EHR.
Main Methods:
- A descriptive correlational study was conducted over 15 days involving 28 patients in a neurovascular ICU.
- Verbal goals from daily interdisciplinary rounds were compared with their presence and related actions in the EHR over 24 hours.
- Descriptive statistics and chi-squared analyses were used, with inter-coder reliability assessed.
Main Results:
- One-quarter of stated goals were not documented in the EHR.
- Undocumented goals were associated with a 60% decrease in the likelihood of documented related actions.
- Ventilator weaning goals were more frequently documented (81%) in physician notes than sedation weaning goals (49%), with sedation goals absent from structured nursing documentation.
Conclusions:
- Current EHR documentation tools may be insufficient for capturing essential ICU patient care goals.
- Improved EHR functionalities are needed to accurately reflect interdisciplinary care plans, particularly for sedation management.
Related Concept Videos
01:11Guidelines for Writing Outcome
When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care evaluation by...
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care evaluation by...
01:27Nursing Clinical Information System
Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
01:21Methods of Documentation III: PIE
Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
01:15Methods of Documentation VI: Case Management Model
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
For example, a patient with a chronic illness...
01:30Guidelines for Nursing Documentation I
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:25Role of Communication in the Nursing Process II: Planning and Implementation
Several factors are considered while creating a patient's care plan. Motivation is a factor in improving communication, and patients often require encouragement to try different approaches involving significant change. It is essential to involve the patient and family in decisions about the plan of care to determine whether the suggested methods are acceptable. Consider meeting critical comfort and safety needs before introducing new communication methods and techniques. Allow adequate time for...