Construction and application of ICU nursing electronic medical record quality control system

Abstract

Abstract Background: In addition to providing intensive nursing care to critically ill patients, ICU nurses are also responsible for documenting standardized electronic medical records. This includes recording vital signs, nursing interventions, medication administration, and pipeline assessments on an hourly basis. With the widespread adoption of information technology, ICU wards in China have successfully integrated monitor and ventilator data with electronic medical records, allowing for real-time capture of data throughout the entire duration of care. Currently, if the patient exhibits actions such as coughing or rolling over, or other human-related factors, the vital signs column of the nursing electronic medical record may contain pseudo-data. Furthermore, ICU nurses may be occupied with attending to critically ill patients, potentially leading to overlooked assessments of pain, nutritional tolerance, restraints, and other conditions. Moreover, the conventional quality control method for electronic medical records often involves manual verification, which is known for being time-consuming, prone to high omission rates, and subject to significant subjectivity. Furthermore, the transmission of crucial information by doctors to the succeeding shift nurses often takes the form of verbal handover, which frequently results in omissions or deviations, thereby compromising the accuracy of the shift handover. Consequently, there is an imperative requirement to enhance the standardization rate of electronic medical records in ICU nursing and improve the accuracy of handover through the utilization of information technology. Objective:The purpose of this study is to develop a quality control system for electronic medical records in ICU nursing and investigate its impact on clinical practice. Design:The design of this study is prospective controlled trial. Methods: In this study, a research team was formed to investigate the quality control of electronic medical records (EMRs) in the Intensive Care Unit (ICU). The team utilized the ICU nursing EMR system as a foundation and employed group brainstorming techniques to design quality control rules for the EMRs. Additionally, the team collaborated with information engineers to construct an ICU nursing EMR quality control system. This system enables real-time data collection and facilitates quality control measures for patient vital signs, medication management, nursing evaluation, and shift handover. Furthermore, the system incorporates dynamic reminders and ensures the quality control of electronic medical records. The study involved a sample of 120 patients who were admitted to the intensive care unit (ICU) of a tertiary hospital in Zhejiang Province between January and December 2023. The implementation of the ICU nursing electronic medical record quality control system commenced in July 2023. A comparison was made between the time spent by nurses on medical record quality control before the system's implementation (January to June 2023) and after its implementation (July to December 2023). Additionally, the study examined the nurses' satisfaction with the system, as well as the total missed rate of nursing evaluation. Results: After the use of the ICU nursing electronic medical record quality control system, there was a significant reduction in the prevalence of inaccurate vital signs in the ICU EMRs, from 9% to 1.33%. Additionally, there was a decrease in medication administration compliance rates from 3.33% to 1.67%, and assessment completion rates decreased from 8% to 1.33%. Besides, the average electronic medical record quality control time spent per electronic medical record was 62(48,76) seconds, which was significantly lower than the traditional quality control time spent in 264(195.5,337.5)seconds. The nurses' satisfaction with the nursing electronic medical record quality control was (105.73±9.31). Conclusions: The ICU nursing electronic medical record quality control system can reduce the time spent by nurses on the quality control of nursing electronic medical records, improve the satisfaction of nurses with the quality control of nursing electronic medical records, and significantly reduce the rate of missed evaluation of nurses in ICU nursing documents through this system.