Documentation in medical records improves after a neurointensivist’s appointment

Abstract

Introduction: Medical documentation is important for communication among health care professionals, research, legal defense, and reimbursement. Previous studies have indicated insufficient documentation by health care providers and resistance among physicians to comply with the new guidelines. Data in the intensive care unit (ICU) subpopulation are scarce. We examined the hypothesis that a newly appointed neurointensivist may alter documentation practices in a university hospital setting.

Methods: We sampled medical records of neurological intensive care unit (NICU) patients admitted with three specific diagnoses (head trauma, intracerebral hemorrhage, and subarachnoid hemorrhage) and examined changes in the documentation of important prognostic variables in two time periods: before and after the appointment of a neurointensivist.

Results: Overall, documentation improved from 32.5 to 57.5% (odds ratio, 95% confidence interval 2.8, 1.9–4.2) in the after period. Documentation using Glasgow Coma Scale, clot volume, Hunt & Hess scale, and Fisher’s grade also improved significantly in each of the diagnoses examined in the after period.

Conclusions: Our findings suggest that a major change was implemented in the NICU regarding documentation after a neurointensivist was appointed. Although the direct or indirect impact of the appointment was not clarified, these preliminary data warrant a prospective ICU study, which should determine the exact variables that play a role in documentation, how they change over time, and what reinforcing mechanisms can be used.