This study examined the degree to which electronic documentation reflected goals that were stated during interdisciplinary rounds in an NICU. A mean of 24.4% of stated goals were not present in the EHR. The range of goals that were present within the documentation was 14.3–100% depending on the type of goal. These findings are comparable to those of a related study by Chisholm et al
that identified discrepancies between observations of emergency physicians' assessments and treatments of pain and their documentation.15
Chisholm et al
found that the physicians documented 91.7% of their pain assessments, but documented only 31.7% of their pain treatments.15
If a stated goal was not documented, it was over 60% less likely that an action related to that goal was documented (17% vs 45%). However, all conflicting documentation still had a correct action documented. Although we cannot assume that documentation provides hard evidence of an action, it is likely that most documented activities were actually completed.7
These findings support the need for the explicit documentation of common goals that are discussed during rounds.
The attending's note was the most likely place for the stated goals to be documented, and the note reflected the discussions of all ICU team members. This finding suggests that, despite the fact that the EHR system observed in our study does not have a centralized interdisciplinary note, the NICU clinicians treated the attending note as a centralized patient-focused note. However, documentation rates depended on the type of goal and clinician. For instance, ventilator goals were documented about 1.5 times more often than sedation goals (97.6% vs 60.5%). Variable documentation rates may lead to inconsistent information within the EHR. Shaver et al
's study, which analyzed the documentation rates of sedation-related events, also found similar documentation inconsistencies, with only 9% agreement between nursing and physician EHR documentation for sedation-related events (95% CI 2 to 16; κ=0.13).16
Therefore, to maintain EHR data integrity, data should be entered once, verified if needed, and reused. Once documented, information should be accessible to clinicians for various purposes (eg, ordering, listing, and planning), and patient updates should be automated throughout the EHR to avoid inefficiencies and errors in clinical care.17
Therefore, the practice of documenting goals in one location may be beneficial to information exchange.
The three most commonly stated goals were ‘wean ventilator’ (N=32), ‘wean sedation’ (N=29), and ‘do not wean sedation’ (N=14). Overall, documentation of ventilator goals was high for all clinician types. However, only 35.7% of the ‘do not wean sedation’ goals were documented. Given that weaning sedation is a prerequisite activity to allow a patient to breathe without a ventilator, it may be clinically important that 64.3% of the documentation to indicate sedation should not be weaned was missing. This result may be an artifact of the EHR, which supported nurses' structured documentation of ventilator goals, but not sedation goals.
The lack of documentation related to sedation goals was also observed in attending documentation. The attending note included a stated sedation goal (‘wean sedation’/‘do not wean sedation’) only 49% of the time, compared with a stated ventilator goal 81% of the time. Similarly, Shaver et al
found low rates of EHR documentation of sedation-related events compared with an event-reporting system for sedation-related events.16
Nursing EHR documentation contained 40% of the sedation events (95% CI 28 to 53), and the physician documentation contained only 20% of the sedation events (95% CI 11 to 32). The efficacy of nurse-led sedation weaning has been demonstrated in a number of studies.19–21
It was observed that the nurses would suspend sedation before rounds to allow the team to assess the patient's neurological status without a sedative effect, and during rounds the nurses initiated many sedation-related discussions. Therefore, if sedation weaning is considered a nursing activity, then the attending, as well as the resident and respiratory therapist, may be less likely to document sedation goals versus ventilator goals in his or her note. Moreover, the attending's note is the supporting documentation used for professional billing22
; if sedation weaning is not a billable goal or action, then attending physicians may be less likely to include this information in their notes. An alternative explanation for the different documentation rates of ‘wean ventilator’ versus ‘wean sedation’ is that the goal of weaning sedation may be implicitly understood to be a necessary part of the process of weaning the ventilator. This may be an example of charting by exception23
in that documenting the goal ‘wean sedation’ may be unnecessary, and it may only be necessary to explicitly state the goal ‘do not wean sedation’ when it is inappropriate to wean sedation. However, the rates at which the goals ‘wean sedation’ (72.4%) and ‘do not wean sedation’ (35.7%) were documented imply that charting by exception, with ‘do not wean sedation’ as the exception, may not be an explanation of the disparate documentation rates between sedation goals and ventilator goals. In other words, if charting by exception was occurring on the NICU, then the exception, ‘do not wean sedation’, should be documented at a higher rate than the normal plan of care. Such an example points to the difference between ‘continuation of care’ goals versus ‘change in care’ goals. However, the interpretation of a goal as a continuation or change is dependent on the patient's previous state; ‘wean ventilator’ may be considered either type of goal, depending on the patient. Further research should investigate ‘continuation’ versus ‘change’ goals.
The nurses' omission of information in documentation, such as in the example of the nurse weaning the ventilator based on the patient's brain oxygen level, may not only be a result of the lack of EHR structure for the explicit documentation of goals as they relate to actions. Keenan and Yakel also demonstrated that nurses omit information that was used in practice and communicated to others, such as judgments and decisions.24
Nurses may assume that these pieces of information are understood by others to be part of standard nursing practice and therefore do not warrant explicit documentation.24
Yet, billing codes are used to reflect the patient care delivered by a healthcare provider, and the completeness, accuracy, and preciseness of these codes are used to determine evidence to support clinical decision-making and healthcare policy.25
It is possible that nurses' omission of information in documentation may be a downstream effect of the fact that nurses do not bill independently for their services. Therefore, a nurse's documentation is not used for a secondary purpose that requires that it demonstrate a link between the nurse's professional practice judgments and activities and the patient care that was delivered. The act of not documenting information that is verbally communicated by nurses has implications for the nursing profession by concealing an important dimension of nurses' work.26
Additionally, the concealment of nurses' work, by omitting documentation of clinical judgments, may have clinical significance to patient care, nursing knowledge development, and efforts to improve patient care practices.
The use of the attending ICU note for multiple purposes may have some patient safety implications if these multiple purposes are not explicitly understood by all members of the ICU team. The use of the note for billing purposes is currently specific to the attending. A lack of common ground regarding the purpose and intended use of the attending ICU note exists if some members of the ICU team view the attending ICU note as the record of the interdisciplinary common goals discussed during ICU interdisciplinary morning rounds and the attending views the note as a billing record.22
The attending may not include some goals that he or she considers to be part of the nursing domain because he or she cannot bill for those goals; therefore, a night shift nurse may not be aware that the attending ICU note is an incomplete record of the interdisciplinary goals that were discussed during rounds. Furthermore, we concluded that the attending leading rounds and interruptions did not affect the documentation of goals; however, future research should investigate how other environmental and clinical factors affect documentation rates, such as overnight events, patient status, length of stay, or time lag to documentation.
The limitations to this study include the single setting of one specialty neurovascular ICU at a large academic medical center using a commercial EHR. The data collection was performed by one researcher, yet our inter-coder reliability (κ) was between 0.82 and 1.00 for 13% of the sample. Data regarding changes to the plan of care after rounds were not collected; therefore, our data did not reflect instances when a goal was changed or an action related to a goal was not performed for a clinically appropriate reason.