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Electronic Medical Record Validation: Exploring the Reliability of Intracranial Pressure Data Abstracted From the Electronic Medical Record–Pilot

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Background and Purpose: Intracranial pressure (ICP) monitoring is crucial to decision making for neurologically injured patients, yet measurement of ICP varies greatly among practitioners. Methods: Unblinded, nonrandomized, observational pilot study comparing ICP values collected using pen and paper (P&P), electronic medical record (EMR), and video data with continuous data acquisition (CDA) technology. Results: ICP values did not significantly differ between EMR and P&P records, despite an average of 16 minutes difference in reporting times. ICP values varied significantly when comparing CDA data to EMR or paper. Conclusion: The results of this pilot study put in to question the validity of ICP values that are recorded in the medical record, which has implications for patient care and research.
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Keywords: DOCUMENTATION; EXTERNAL VENTRICULAR DRAIN; INTRACRANIAL PRESSURE; NURSING

Document Type: Research Article

Affiliations: The University of Texas Southwestern Medical Center, Dallas, Texas, USA

Publication date: December 1, 2015

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