Diagnosis Documentation of Critically Ill Children at Admission to a PICU*

Abstract

OBJECTIVES:Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission. DESIGN:Retrospective mixed methods study describing diagnosis documentation in electronic health records.

Editor’s Choice Articles for February

“…Vivtcharenko VY, Ramesh S, Dukes KC, et al: Diagnosis Documentation of Critically Ill Children at Admission to a PICU (4).…”

The Lost Art of Documentation*

“…The study by Vivtcharenko et al (10) adds to the body of literature highlighting suboptimal documentation practices. However, in order to move forward in understanding the true implications of this issue, what is needed are more studies that investigate how diagnosis documentation affects medical decision-making, patient care, and outcomes.…”

“…In this issue of Pediatric Critical Care Medicine , Vivtcharenko et al (10) examined diagnosis documentation in 100 admission notes for children (0–17 yr) admitted to a single PICU over 1 year. The study sought to describe the type of information clinicians include with diagnoses and to explain how clinicians interpret and integrate clinical information to create a narrative around diagnoses.…”