Background
Methods
Study design
Data collection
Analytic approach
Descriptive analyses
Content analyses
Results
Findings from quantitative descriptive analyses
Documentation, readability, and mode of communication
Measures | Total (n = 7052) | ICU stay (n = 1966) | Transfer day (n = 1207) | Ward stay (n = 3879) | p valuea |
---|---|---|---|---|---|
Mean number of notes per day (per patient) | 2.1 [1.9–2.3] | 2.4 [2.2–2.6] | 2.8 [2.6–3.0] | 1.8 [1.6–2.0] | p < 0.001 |
Handwritten | 97% [92–100%] | 93% [87–100%] | 93% [87–100%] | 100% [94–100%] | p < 0.001 |
Legible | 87% [78–96%] | 86% [77–95%] | 87% [78–96%] | 87% [78–96%] | p = 0.458 |
Date included | 95% [92–98%] | 95% [92–98%] | 96% [93–99%] | 95% [92–98%] | p = 0.778 |
Time-stamped | 49% [40–58%] | 51% [41–61%] | 54% [44–64%] | 46% [36–56%] | p = 0.006 |
Signature/name | 48% [34–62%] | 48% [34–62%] | 48% [34–62%] | 47% [33–60%] | p = 0.630 |
Mean number of lines per note (per patient) | 17.6 [15.9–19.3] | 21.1 [19.1–23.1] | 19.6 [17.6–21.6] | 15.0 [13.1–17.0] | p < 0.001 |
ᅟPatient historyb | 10% [7--13%] | 11% [9–14%] | 11% [8–13%] | 7% [5–10%] | p < 0.001 |
ᅟPatient datab | 59% [54–64%] | 57% [52–62%] | 58% [53–63%] | 61% [56–66%] | p < 0.001 |
ᅟPatient care planb | 31% [26–37%] | 32% [26–37%] | 32% [26–38%] | 31% [26–37%] | p = 0.701 |
Communicationc | 9% [7–10%] | 7% [5–9%] | 8% [6–10%] | 9% [7–11%] | p = 0.071 |
ᅟProvider-providerd | 56% [50–62%] | 64% [56–73%] | 62% [52–72%] | 51% [44–59%] | p = 0.012 |
ᅟProvider-familyd | 23% [16–29%] | 23% [15–31%] | 22% [12–31%] | 22% [15–29%] | p = 0.851 |
ᅟProvider-patientd | 38% [33–43%] | 29% [20–38%] | 36% [26–46%] | 43% [35–50%] | p = 0.007 |