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Accuracy of Electronic Health Record Documentation of Parental Presence: A Data Validation and Quality Improvement
Abigail Shuman1, Karl Umble2, Dana B McCarty3
1Medicine, Georgetown University School of Medicine, Washington DC, USA.
Insights
Electronic health records (EHR) can accurately track parental presence in the neonatal intensive care unit (NICU). Documentation accuracy varies by shift and recording method, offering insights for improving data collection.
Area of Science:
- Healthcare Informatics
- Neonatal Medicine
- Data Science
Background:
- Parental presence in the neonatal intensive care unit (NICU) positively impacts infant health outcomes.
- Electronic health records (EHR) offer potential for analyzing parental presence and sociodemographic factors.
- Limited evidence exists on the accuracy of non-clinical data, such as parental presence, within EHRs.
Purpose of the Study:
- To validate the accuracy of EHR documentation for parental presence in the NICU.
- To compare EHR data with observational logs to assess agreement.
- To identify factors influencing the accuracy of parental presence documentation in EHRs.
Main Methods:
- A data validation study comparing an observational log of parental presence with EHR documentation.
- Calculation of percentage agreement between the two data sources.
- Stratification of accuracy by shift (day vs. night) and documentation type (flowsheet vs. plan of care notes).
Main Results:
- High overall accuracy was observed when combining observational logs and EHR data.
- Night shift documentation in EHRs was more accurate (76.3%) than day shift documentation (55.2%).
- Flowsheet (FS) recordings (82.4%) demonstrated higher accuracy than free-text plan of care (POC) notes (75.1%).
Conclusions:
- EHR documentation of non-clinical factors like parental presence can be accurate.
- Documentation accuracy is influenced by the time of day and the specific EHR recording method used.
- This study provides a methodological framework for future research utilizing EHR data for non-clinical variables.
Abstract:
Parental presence in the neonatal intensive care unit (NICU) is known to improve the health outcomes of an admitted infant. The use of the electronic health record (EHR) to analyze associations between parental presence and sociodemographic factors could provide important insights to families at greatest risk for limited presence during their infant's NICU stay, but there is little evidence about the accuracy of nonvital clinical measures such as parental presence in these datasets. A data validation study was conducted comparing the percentage agreement of an observational log of parental presence to the EHR documentation. Overall, high accuracy values were found when combining two methods of documentation. Additional stratification using a more specific measure, each chart's complete accuracy, instead of overall accuracy, revealed that night shift documentation was more accurate than day shift documentation (76.3% accurate during night shifts, 55.2% accurate during day shifts) and that flowsheet (FS) recordings were more accurate than the free-text plan of care (POC) notes (82.4% accurate for FS, 75.1% accurate for POC notes). This research provides a preliminary look at the accuracy of EHR documentation of nonclinical factors and can serve as a methodological roadmap for other researchers who intend to use EHR data.
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