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Diagnosis Documentation of Critically Ill Children at Admission to a PICU
Victoria Y Vivtcharenko1, Sonali Ramesh2, Kimberly C Dukes3,4
1University of Iowa Carver College of Medicine, Iowa City, IA.
Insights
Pediatric critical care clinicians document primary diagnoses and diagnostic uncertainty in most PICU admission notes. However, the way information is presented varies significantly, impacting clinical decision-making.
Area of Science:
- Pediatric critical care medicine
- Clinical informatics
- Healthcare documentation
Background:
- Effective information sharing is crucial for multidisciplinary Pediatric Intensive Care Unit (PICU) teams caring for critically ill children.
- Clinical documentation aids shared understanding of patient diagnoses, informing critical decision-making.
- Diagnosis-related documentation in the PICU is understudied, limiting insight into pediatric intensivists' diagnostic reasoning.
Purpose of the Study:
- To describe how pediatric critical care clinicians document patients' diagnoses upon PICU admission.
- To analyze the methods and content of diagnosis documentation in the PICU setting.
Main Methods:
- Retrospective mixed methods study.
- Analysis of 100 PICU admission notes from 96 unique pediatric patients admitted to an academic tertiary referral PICU over one year.
- Review of diagnosis documentation, including format, presence of rationale, and expression of diagnostic uncertainty.
Main Results:
- Primary diagnoses were documented in 87% of notes by attending physicians and residents/advanced practice providers, and in 13% by residents/advanced practice providers alone.
- Most diagnoses (72%) were documented as narrative free text, with 11% as problem lists/billing codes and 17% using both formats.
- A rationale for the primary diagnosis was documented in 91% of notes. Diagnostic uncertainty was present in 52% of notes, often indicated by uncertain language (65%) and differential diagnoses (60%).
Conclusions:
- Most PICU admission notes include a rationale for the primary diagnosis and indicate diagnostic uncertainty.
- Significant variation exists in how clinicians organize diagnostic narratives, utilize contextual details, and express uncertainty.
- Further research is needed to understand the impact of diagnosis narratives on clinical decision-making, patient care, and outcomes in the PICU.
Objectives:
Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission.
Design:
Retrospective mixed methods study describing diagnosis documentation in electronic health records.
Setting:
Academic tertiary referral PICU.
Patients:
Children 0-17 years old admitted nonelectively to a single PICU over 1 year.
Interventions:
None.
Measurements And Main Results:
One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty.
Conclusions:
In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
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