Electronic documentation enhances accuracy and information gathering

Electronic charting has allowed this respiratory care department to improve efficiency and patient care.

Advances in information technology have accelerated the growth of information-gathering systems, so much so that electronic documentation has become an element of all aspects of society.1 The accurate documentation of vital clinical information is essential when examining the effect of interventions on patient outcomes.2 Precise documentation becomes even more paramount when patient safety concerns need to be assessed. Tracking patient safety indicators, determining clinician compliance regarding the utilization of ventilator bundles, or trending the incidence of accidental extubations can be time-consuming and often is less than accurate.3 With electronic documentation, retrieving patient data is quicker and more efficient, with a reduced chance of error.4 The use of electronic charting gives the bedside clinicians another tool to use to ensure high-quality patient care.

All of the professionals treating a given patient have the need to document clinical assessments and performed interventions,5 and they need to coordinate and have equal assess to all documented information. Electronic documentation allows multiple providers to document spontaneously and also to evaluate other clinician assessments. The coordination and gathering of this information can be done by the development of individual queries or databases. Compliance with performance improvement initiatives or the observation of safety indicators is an additional benefit garnered from electronic documentation.6 We examined the documentation of reporting patient safety indicators after the implementation of electronic monitoring.

As medical professionals, we are continuously trying to find ways to document accurate data, but our ability to query and retrieve different pieces of that data has always been a complex process. In the past, members of the health care team spent many hours poring through traditional patient records for different points of data. At times, this data was not even recorded, and, when it was documented, each clinician had a different method of documentation. The frustration that occurred in this process could make the data collection inaccurate. Individuals would make assumptions about what other clinicians meant, and those assumptions would lead to other inaccuracies in the data collection and reporting.

Although the importance of collecting exact data has really never changed, it is now looked at from a different perspective. With the creation of Medicare Bill CMS 1533-P, which dictates that when patients develop a hospital-acquired infection, payment for treatment will be minimized or absent,7 accurate documentation and data collection have an even bigger impact than in the past. The ability to collect, collate, and report this data has now become a major requirement for most respiratory care departments across the country.8 The ability of respiratory care practitioners to now collect and report data has placed them on the radar screen of hospital administration.9 The department has now become a major player in the prevention of ventilator-acquired pneumonia (VAP)—specifically, because of our ability to perform quality assurance for our department to make sure each ventilated person is assessed on a daily basis for their ability to wean. If deemed clinically stable, a spontaneous breathing trial is performed on these people each day. Our electronic charting now allows the management team to perform a query at the end of each month to make sure that the bedside therapists are assessing their patients on a daily basis. Although not each patient will have a spontaneous breathing trial every day, at least they are being assessed for their ability to wean each day.

Everyone Gets Counted

Electronic charting allows us to perform this task more efficiently than was possible with a traditional paper chart. In the past, we would have the clinical coordinator perform assessments on random therapists to see if spontaneous breathing trials were being performed. This checking was often done sporadically or only on a selected group of therapists. This method often revealed inconsistent data and therapist compliance. Now with electronic charting, the coordinators are freed from this duty, and assessments can be checked by our clinical information system specialist. The time that it now takes to check the data has been reduced by 75%, and data can be checked and compiled for every patient—not just a select few. This eliminates the assumption that all patients not checked had similar assessments performed and correct data documented. When we started our electronic collection, we realized that the compliance numbers that had been historically documented were far from the actual number of staff compliance. Armed with this information, we were able to set up an action plan to reeducate the staff performing ventilatory assessments for spontaneous breathing trails. We have now been able to increase our compliance with performing ventilatory assessment and spontaneous breathing trails to above 96% on a consistent basis.

As with the VAP information, we have found other ways to improve the quality of care we deliver to our patients. Each month, we examine the number of patients who are liberated from mechanical ventilation to ensure that a spontaneous breathing trial was performed and documented. Along with the time they are liberated, we document the reason for their extubation/liberation, eg, withdrawal of care, adequate pulmonary mechanics.

Prior to electronic charting, this information was obtained through a chart review, with the hope that information would clearly document why the patient was removed from mechanical ventilation. Now, utilizing electronic charting, the bedside therapist is given a precise list of clinical reasons for liberation from which to select. Documentation of the time of extubation is entered into the electronic chart, and the therapist also documents the clinical indication for mechanical ventilation. This allows us to determine if it is an initial intubation, a failed extubation (patient intubated with 24 hours of extubation), or a patient reintubated after 24 hours of extubation/liberation. Having all this data available allows the physician to track whether a self-extubated patient was reintubated or if there was a successful extubation; they then can compare those outcomes to all the other patients being extubated/liberated from the ventilator in the institution.

One of the great advantages of the entire system is the amount of time it takes to report the data to the physicians on a monthly basis. With electronic documentation, there has been a transition from data being 2 months late to having the data within a few hours at the end of each month.

A Team Effort

Transition did not happen immediately, but once we understood how the system can work in a more efficient manner, it has given us a greater ability to collect and examine data. Successful implementation includes in-services to the staff on the new way of charting; it also takes some consistent reminders to provide accurate documentation. Electronic charting has made our documentation a very important tool to improve the quality of the care we provide to our patients.

Without the great number of team players involved in the process, successful implementation would not have been possible, and we could not have advanced to where we are today. The effort provided by the physicians, nurses, respiratory therapists, and information service department all contributed to the success we have had in making this a very functional system. Based on the information we have gained regarding our clinical practices, we have made improvements in helping to optimize our patient outcomes.10

Kenneth Miller, MEd, RRT-NPS, is clinical educator for respiratory care; Robert N. Leshko, BS-RRT, CCSI, is clinical information system specialist; and Matthew McCambridge, MD, is chief of critical care medicine, Lehigh Valley Hospital, Allentown, Pa.


  1. Greenes RA, Shortliffe EH. Medical informatics: an emerging academic discipline and institutional priority. JAMA. 1990;263:1114-20.
  2. Mussa C, Langsam Y. Management and processing of respiratory care information in respiratory care departments. Respir Care. 2007;52:730-9.
  3. Pronovost P, Thompson D, Holzmueller C, Lubomski LH, Morlock LL. Defining and measuring patient safety. Crit Care Clin. 2005;21:7-15.
  4. Hammond KW, Helbig ST, Benson CC, et al. Are elctronic medical records trustworthily? AMIA Annu Symp Proc. 2003:269-73.
  5. Mussa C. Respiratory care informatics and the practice of respiratory care. Respir Care. 2008;53:488-99.
  6. Howard WR. Development of an affordable data collection, reporting and analysis system. Respir Care. 2003;48:131-137.
  7. Medicare program; Proposed changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates CMS-1533-P. Centers for Medicare and Medicaid Services. Available at: www.cms.hhs.gov/Quarterly ProviderUpdates/. Accessed September 26, 2008.
  8. Ford RM. Respiratory care management information systems. Respir Care. 2004;49:367-75.
  9. Howard WR. Respiratory care billing using a personal digital assistant. Respir Care. 2004:1339-48.
  10. Leshko R, Miller K, McCambridge M, Lutz A, Baker K. Electronic documentation provides consistent data collection regarding failed extubation rates. Respiratory Care Open Forum #13. To be presented at the 54th International Respiratory Congress, Anaheim, Calif.