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Studies related to documentation of vital signs:


Meg Meccariello, Dave Perkins, et al, (2010) at St. Josephs Hospital Health Center. New York conducted a study on Evaluating the Use of an Automated Vital Signs Documentation System on a Medical/Surgical Unit Vital signs documentation was the focus of this study, because multiplication errors, transcription errors, illegible results, late data entry, misidentification of the patient, undocumented readings and missed readings can lead to faulty data, as well as unnecessary and potentially dangerous interventions or withholding of treatments. Technology is now available to medical/surgical units that automate the vital signs documentation process. This study compared the accuracy and time efficiency of manual-entry vital signs documentation with workflows that use a data management system to automatically transfer vital signs assessments from a bedside vital signs device into the electronic medical record. The study found that the automated vital signs documentation system was more accurate than manual documentation and errors were reduced by 75 percent. The wireless automated vital signs documentation system saved time compared to manual documentation: and combined vital-signs acquisition/ documentation times were reduced on average by 96 seconds per reading.


Madineh Jasemi, Vahid Zamanzadeh (2010) at Tabriz Teaching Hospitals, Tabriz conducted a study To explore adequacy of nursing documentation and nurses' knowledge about the process. The study was a cross-sectional study. The data were collected from 170 nurses who selected to participate in the study with census sampling method from 32 Medical Surgical units at four university hospitals in Tabriz. For assessing the quality of nurses' documents, 2040 documents that were selected with simple random sampling were reviewed for content based on nursing process, legal accuracy, chronology and common items in flow sheets. Checklists were provided covering four areas: nursing records, drug interventions, vital sign and I & O of fluids. Nurses' knowledge were evaluated by prepared questionnaires. Data was analyzed by SPSS software using One-way ANOVA and independent t test. The results showed that all of nursing records and vital sign flow sheets had average quality and insufficient information in legal accuracy, nursing care processes, and common items sections in vital sign flow sheets but most of fluids I & O flow sheets

(81.4%) and drug interventions (85.9%) had good quality; however some degree of deficiency was present in these two sections, too. Most participants (85.9%) had limited knowledge regarding nursing documentation process.
3) Yeung MS, Lapinsky SE, et al, (2012) conducted study on Examining

nursing vital signs documentation workflow at University Health Network, Institute of Biomaterials, Toronto, Canada. The study was Qualitative ethnographic analyses and quantitative time-motion study. A sample of 24 nurses at three hospitals in five general internal medicine environments were captured, and timeliness of vital signs assessment and documentation was measured. Study concluded that Clinical assessment of vital signs was consistent, but the documentation process was highly variable within groups and between hospitals. Two themes characterized workflow barriers surrounding pointof-care documentation. First, a lack of standardized documentation methods for vital signs resulted in higher rates of transcription, increasing not only the likelihood of errors but delays in recording and accessibility of information. Second, despite advancements in electronic documentation systems, the observed system was not conducive to point-of-care documentation. Average electronic documentation was significantly longer than paper documentation. Wager KA, Schaffner MJ, et al,(2013) conducted a study on Comparison of the quality and timeliness of vital signs data using three different data-entry devices, at Medical University of South Carolina, Charleston, USA. An observational study was conducted at a large academic medical center. Patient observations (n = 270) were completed as patient care technicians made routine vital sign rounds. Equipping patient care technicians with a Tablet PC affixed to the vital signs monitor significantly improved (P < .05) the accuracy and timeliness of vital signs. In addition, a number of unintended consequences were discovered that proved helpful to the nurse managers and nursing informatics leadership team in providing support of the new system. Findings from this study emphasize the importance of ensuring that staff has the appropriate devices needed to effectively document patient care at the bedside. Forbes McGain, Michelle A Cretikos, et al, (2012) conducted study on Documentation of clinical review and vital signs after major surgery at five Australian hospitals. A retrospective audit of patient records in each of the five participating Australian hospitals. Hospitals were located in Victoria or New South Wales and were referral or tertiary metropolitan institutions.



Patients aged less than 18 years were excluded. Sample was patients who had undergone one of 14 major surgical operations, identified by the International classification of diseases. During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Study concluded that respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends.
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