From the College of Computing and Informatics, Drexel University, Philadelphia, PA.
School of Physician Assistant Studies, University of Florida College of Medicine, Gainesville, FL.
Pediatr Emerg Care. 2021 Aug 1;37(8):e436-e442. doi: 10.1097/PEC.0000000000001676.
Despite growing use of electronic health records, many resuscitation settings still use paper-based documentation. The fast-paced and safety-critical nature of trauma and medical resuscitation environments pose challenges for real-time documentation. This study aims to understand paper-based documentation practices and inform the design of efficient electronic documentation solutions for supporting safety-critical medical processes.
Data were collected through in situ observations of nurse documenters during resuscitation events and postevent interviews with nurses. These data were analyzed using frequency distribution and qualitative, open-coding techniques. Data analysis focused on the following 3 main documentation factors: temporal distribution of documentation, total number of filled out sections on the paper flow sheet across all resuscitations, and completeness of documentation per resuscitation.
Findings from this study highlight the time-critical nature of these settings, showing that 74% of the documentation was completed within the first 15 minutes of the resuscitation. Some sections of the paper flow sheet were filled out more than others, and a few sections were left incomplete across all events. Interviews with nurses provided insight about documentation experiences in a fast-paced environment, including variable usage of flow sheet based on nurse experience level and patient scenarios, supplemental documentation mechanisms, and information needs and preferences.
Several design implications are discussed to inform the design of effective electronic documentation systems. Design implications focus on layout structure, prepopulating items, section placement, and completion status of the flow sheet. Future plans for research focus on combining video review with in situ observations and conducting detailed interviews with nurses to better understand their documentation experiences and preferences.
尽管电子健康记录的使用日益增多，但许多复苏环境仍使用基于纸张的文档。创伤和医疗复苏环境的快节奏和安全关键性质对实时文档记录提出了挑战。本研究旨在了解基于纸张的文档记录实践，并为支持安全关键型医疗流程的高效电子文档解决方案设计提供信息。
通过在复苏事件期间对护士文档记录员进行现场观察以及对护士进行事后访谈来收集数据。使用频率分布和定性、开放式编码技术对这些数据进行分析。数据分析集中在以下 3 个主要文档因素上：文档的时间分布、所有复苏过程中在纸质流程表上填写的部分总数，以及每次复苏的文档完整性。
本研究的结果强调了这些环境的时间关键性质，表明 74%的文档是在复苏的前 15 分钟内完成的。纸质流程表的一些部分比其他部分填写得更多，并且在所有事件中都有一些部分未填写完整。对护士的访谈提供了有关快节奏环境中文档记录体验的见解，包括基于护士经验水平和患者情况的流程表使用情况、补充文档机制以及信息需求和偏好。
讨论了几个设计要点，以提供有关有效电子文档系统设计的信息。设计要点集中在布局结构、预填充项目、部分位置和流程表的完成状态上。未来的研究计划包括结合视频审查与现场观察，并对护士进行详细访谈，以更好地了解他们的文档记录体验和偏好。
