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Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
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Related Experiment Video

Updated: Jun 17, 2025

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
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"Mind the Gap"-Differences between Documentation and Reality on Intensive Care Units: A Quantitative Observational

Florian Jürgen Raimann1, Cornelius Johannes König1, Vanessa Neef1

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Healthcare (Basel, Switzerland)
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Summary

Critical care medication documentation is significantly lacking in digital records. Implementing automated systems can improve accuracy and reduce staff workload for better patient care.

Keywords:
catecholaminescritical carepatient safetyrisk managementsedation

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Area of Science:

  • Critical care medicine
  • Health informatics
  • Pharmacology

Background:

  • Digitalization in healthcare presents challenges in balancing documentation accuracy with limited staff resources.
  • Accurate medication administration records are crucial for patient safety and effective treatment in intensive care units (ICUs).

Purpose of the Study:

  • To evaluate the adherence and identify documentation gaps in the administration of critical care medications.
  • To compare manual checklist documentation with digital records in the hospital information system (HIS).

Main Methods:

  • Data from HIS and paper-based checklists for medication boluses (sedatives, analgesics, catecholamines) were collected from ICUs (2019-2022).
  • A comparative analysis was performed between documented administrations and digital records within the HIS.

Main Results:

  • A significant under-documentation of medication administration was observed, with only 12% of catecholamines and 11% of α2-agonists recorded digitally.
  • Documentation gaps varied by shift, day of the week, and ICU discipline, with anesthesiology ICUs showing significant differences (p < 0.0001).

Conclusions:

  • A substantial gap exists between administered and digitally documented medication boli in critical care settings.
  • Automated documentation systems, such as connected syringe pumps, can enhance accuracy, reduce workload, and ensure legally compliant record-keeping.