Construction and application of ICU nursing electronic medical record quality control system

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This includes recording vital signs, nursing interventions, medication administration, and pipeline assessments on an hourly basis. With the widespread adoption of information technology, ICU wards in China have successfully integrated monitor and ventilator data with electronic medical records, allowing for real-time capture of data throughout the entire duration of care. Currently, if the patient exhibits actions such as coughing or rolling over, or other human-related factors, the vital signs column of the nursing electronic medical record may contain pseudo-data. Furthermore, ICU nurses may be occupied with attending to critically ill patients, potentially leading to overlooked assessments of pain, nutritional tolerance, restraints, and other conditions. Moreover, the conventional quality control method for electronic medical records often involves manual verification, which is known for being time-consuming, prone to high omission rates, and subject to significant subjectivity. Furthermore, the transmission of crucial information by doctors to the succeeding shift nurses often takes the form of verbal handover, which frequently results in omissions or deviations, thereby compromising the accuracy of the shift handover. Consequently, there is an imperative requirement to enhance the standardization rate of electronic medical records in ICU nursing and improve the accuracy of handover through the utilization of information technology. Objective:The purpose of this study is to develop a quality control system for electronic medical records in ICU nursing and investigate its impact on clinical practice. Design:The design of this study is prospective controlled trial. Methods: In this study, a research team was formed to investigate the quality control of electronic medical records (EMRs) in the Intensive Care Unit (ICU). The team utilized the ICU nursing EMR system as a foundation and employed group brainstorming techniques to design quality control rules for the EMRs. Additionally, the team collaborated with information engineers to construct an ICU nursing EMR quality control system. This system enables real-time data collection and facilitates quality control measures for patient vital signs, medication management, nursing evaluation, and shift handover. Furthermore, the system incorporates dynamic reminders and ensures the quality control of electronic medical records. The study involved a sample of 120 patients who were admitted to the intensive care unit (ICU) of a tertiary hospital in Zhejiang Province between January and December 2023. The implementation of the ICU nursing electronic medical record quality control system commenced in July 2023. A comparison was made between the time spent by nurses on medical record quality control before the system's implementation (January to June 2023) and after its implementation (July to December 2023). Additionally, the study examined the nurses' satisfaction with the system, as well as the total missed rate of nursing evaluation. Results : After the use of the ICU nursing electronic medical record quality control system, there was a significant reduction in the prevalence of inaccurate vital signs in the ICU EMRs, from 9% to 1.33%. Additionally, there was a decrease in medication administration compliance rates from 3.33% to 1.67%, and assessment completion rates decreased from 8% to 1.33%. Besides, the average electronic medical record quality control time spent per electronic medical record was 62(48,76) seconds, which was significantly lower than the traditional quality control time spent in 264(195.5,337.5)seconds. The nurses' satisfaction with the nursing electronic medical record quality control was (105.73±9.31). Conclusions: The ICU nursing electronic medical record quality control system can reduce the time spent by nurses on the quality control of nursing electronic medical records, improve the satisfaction of nurses with the quality control of nursing electronic medical records, and significantly reduce the rate of missed evaluation of nurses in ICU nursing documents through this system. Intensive Care Units Digitalization of nursing Electronic medical record Nursing quality control Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction It has become widely popular to use electronic medical records(EMRs) due to the development of medical informatization(1).Nursing electronic medical record is an important part of the hospital information system, and its quality reflects the nursing quality and management level of medical institutions. EMRs and electronic clinical nursing documentation lead to greater quality, greater completeness, and more patient-centered documentation compared to manual nursing documentation(2).Improvements in patient care can be accelerated with an electronic medical record(3).The National Health Commission of the People's Republic of China released the "Grading Evaluation Standards for the Application Level of Electronic Medical Record Systems" in December 2018. In the six-level electronic medical record standard, it is mentioned that each medical service project should have the functions of process data collection, recording, and sharing. It should be able to display the entire process status and provide real-time data verification, prompts, and control functions based on the knowledge base for this link(4). In addition, the National Health Commission issued the Action Plan for Further Improving Nursing Services (2023–2025) in June 2023, which mentioned that it is necessary to improve the quality of nursing and make full use of information technology to reduce the unnecessary writing burden of clinical nursing, so that nurses have more time to stay close to the clinic and provide direct nursing services to patients(5). In the intensive care unit(ICU), patients are continuously monitored, resulting in huge datasets(6). A large and complex amount of data is recorded in the ICU's EMRs, which undoubtedly increases the nursing workload(7). There is a growing body of evidence suggesting that EMRs integrated with ICU information systems lead to lower in-hospital mortality (8). In addition to providing intensive nursing care to critically ill patients, ICU nurses are also responsible for documenting standardized electronic medical records. This includes recording vital signs, nursing interventions, medication administration, and pipeline assessments on an hourly basis. With the widespread adoption of information technology, ICU wards in China have successfully integrated monitor and ventilator data with electronic medical records, allowing for real-time capture of data throughout the entire duration of care. Currently, if the patient exhibits actions such as coughing or rolling over, or other human-related factors, the vital signs column of the nursing electronic medical record may contain pseudo-data. Furthermore, ICU nurses may be occupied with attending to critically ill patients, potentially leading to overlooked assessments of pain, nutritional tolerance, restraints, and other conditions. At present, the quality control of nursing electronic medical records in many hospitals in China is still dominated by manual spot checks, and the automatic monitoring of electronic medical records has not yet been popularized(9).Moreover, the conventional quality control method for electronic medical records often involves manual verification, which is known for being time-consuming, prone to high omission rates, and subject to significant subjectivity. Since March 2020, our hospital has relied on the hospital information system and in accordance with the core requirements of the National Health Commission's Level 6 electronic medical record application, and successfully passed the National Health Commission's Level 6 electronic medical record assessment in July 2023. In the intensive care unit (ICU), the nurse utilizes the wireless network to connect the monitor, ventilator, and ICU nursing electronic medical record system. This allows for the real-time collection, transmission, and recording of the patient's vital signs, thus minimizing errors associated with manual recording. Furthermore, ICU nurses are able to scan the barcode on the drug execution form using their personal digital assistant (PDA), enabling them to initiate, adjust, and terminate drug administration within the ICU nursing electronic medical record system. This implementation facilitates closed-loop drug management. Despite the convenience of the ICU nursing electronic medical record system for ICU nurses, issues persist including inaccurate data, delayed administration of medications, and incomplete evaluation management. As a result, it has been decided to assign a nurse to conduct daily quality control of ICU nursing electronic medical records. Based on this background, this study successfully implemented an ICU nursing electronic medical record quality control system in clinical practice, aiming to provide ICU nurses with more time to focus on patient care and reduce the time spent on medical record documentation and quality control. The results of this implementation were found to be positive. Methods The study was conducted in the ICU of a tertiary hospital in Zhejiang Province, China, in a single-center, prospective controlled study .The study involved a sample of 600 patients who were admitted to the intensive care unit (ICU) of a tertiary hospital in Zhejiang Province between January and December 2023. ICU nursing electronic medical records quality control (QC)was performed manually before June 2023. QC nurses will periodically check the electronic medical record based on the prescription on a daily basi. As part of tertiary care requirements, nurses are required to record the patient's vital signs, including monitor and ventilator parameters, every hour in their nursing electronic medical record. In cases of change in condition, the recording frequency should be increased. We have implemented a nursing electronic medical record system that is wirelessly connected to monitors, ventilators, and other instruments in our ICU.This ensures that the patient's vital signs are captured and recorded in the nursing electronic medical record(Fig. 1 ). For example, if patient A is mechanically ventilated, the electronic medical record system will collect vital signs from 1AM-12PM. When there is a change in condition, it can also separately capture vital signs per minute, such as heart rate, blood pressure, ventilator tidal volume, etc. ICU QC nurses can check the curve of vital signs in the nursing electronic medical record, and find pseudo-data with the naked eye to make artificial manual modifications. In terms of drug administration, our hospital has implemented closed-loop management of drugs.ICU nurses use Personal Digital Assistant (PDA) to scan Quick Response (QR) codes on drugs to start and end operations. Nevertheless, there may be a situation where the medication is not terminated due to problems such as a malfunctioning network or PDA. Therefore, ICU QC nurses will artificially end the medication, thus creating a closed-loop management of the medication. In addition, ICU nurses are required to assess patients for physical restraints, medication sedation, mental status, and nutritional scores as required. If there are omissions, they are also added manually by the ICU QC nurse. In this study, a research team was formed to investigate the quality control of electronic medical records (EMRs) in the Intensive Care Unit (ICU). The team consists of 3 members, including 1 ICU nurse leader A with a senior professional title, 1 nurse B with a master's degree, and 1 information engineer C. A is responsible for the content scheme construction of the nursing electronic medical record quality control system, B is responsible for reviewing literature and subsequent data collection and statistical analysis, and C is responsible for the construction of the system and technical maintenance during the use process. The team utilized the ICU nursing EMR system as a foundation and employed group brainstorming techniques to design quality control rules for the EMRs. Additionally, the team collaborated with information engineers to construct an ICU nursing EMR quality control system. This system enables real-time data collection and facilitates quality control measures for patient vital signs, medication management, nursing evaluation, and shift handover. Furthermore, the system incorporates dynamic reminders and ensures the quality control of electronic medical records. The ICU nursing electronic medical record quality control module mainly includes three parts: vital signs, drug management, and evaluation management . The vital signs section requires hourly records of the patient's heart rate, oxygen saturation, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and respiration. The patient's body temperature must be measured every 4 hours, specifically at 6:00, 10:00, 14:00, 18:00, 20:00, and 24:00. If the patient is on a ventilator, the vital signs section should also be recorded on an hourly basis, such as respiratory rate, minute ventilation, inhaled tidal volume, exhaled tidal volume, and oxygen concentration. If the above data is missing, the system will remind the nurse to supplement it in time. In addition, if there is an abnormal value in the data collected by the electronic medical record system, such as an exhaled tidal volume of < 150ml, an alert will be given(Fig. 2 ). The nurse will make timely corrections according to the reminder to ensure the accuracy of the data. The drug management part requires strict implementation in accordance with the doctor's instructions. When the micropump injection drug is executed, the infusion speed will be requested, and the medical record quality control system will remind the drug end time according to the set drug speed (Fig. 3 ). Assessment management content and assessment frequency in the electronic medical records of ICU nursing are as follows: Patient position, need for physical restraint to be assessed every 2 hours; skin condition, level of consciousness, pupil size (left/right), upper limb muscle strength (left/right), lower limb muscle strength (left/right), breath sounds, sputum viscosity and volume, urine color, bowel sounds, dorsalis pedis artery pulse (left/right), lower limb edema (left/right), delirium assessment, high-risk pressure injury assessment, pain assessment, Glasgow Coma Scale, and enteral nutrition intolerance assessment to be assessed every 4 hours. If the nurse does not assess within the specified time, the system will pop up a reminder box(Fig. 4 ). Once the ICU nurse completes the assessment in a timely manner, the reminder box will disappear. The implementation of the ICU nursing electronic medical record quality control system commenced in July 2023. A comparison was made between the time spent by nurses on medical record quality control before the system's implementation (January to June 2023) and after its implementation (July to December 2023). Additionally, the study examined the nurses' satisfaction with the system, as well as the patient vital signs, medication management, and evaluation management in nursing EMRs. Date collection In this research, a total of 300 nursing electronic medical records were randomly chosen to undergo manual quality control assessment prior to the implementation of the ICU nursing electronic medical record quality control system (January to June 2023). The manual quality control assessment team comprised five ICU nurses, all holding the position of head nurse. Each nurse was tasked with reviewing 10 different nursing electronic medical records every months, focusing on vital signs, medications, and assessment management sections from the previous 24 hours. The time taken for each record inspection was recorded, from the start to the end of the inspection. Subsequently, following the introduction of the ICU nursing electronic medical record quality control system (July to December 2023), another 300 nursing electronic medical records were randomly chosen for electronic quality control assessment. Similarly, each of the five nurses randomly selected 10 nursing electronic medical records for inspection every months. The nurses utilized the quality control system to prompt them to review the nursing electronic medical records from the previous 24 hours, and the time taken for each electronic medical record inspection was recorded. The inclusion criteria for the selected medical records were patients over 18 years old who had stayed in the ICU for longer than 24 hours. The study utilized the clinical nursing information system effectiveness evaluation scale developed by Zhao(10)to assess nurses' satisfaction with the restraint management system. This scale comprises five dimensions: system quality, information quality, service quality, user satisfaction, and net benefits, with a total of 23 items. Each item is rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The total score ranges from 23 to 115, with a higher score indicating greater satisfaction with the management system. Statistical analysis This study used R version 3.5.3 to analyze the data in this study. Means and standard deviations for metrics with normally distributed data were analyzed using t-tests, while medians and quartile were used for metrics with non-normal distributions .Analyses were conducted using the non-parametric test, and counts were described by frequency and percentage using the χ2 test.An analysis with a p-value of 0.05 was considered statistically significant . Results Prior to and subsequent to the implementation of the ICU nursing EMR quality control system, 300 patient cases were analyzed to compare gender, disease diagnosis, and length of ICU stay. The results showed no statistically significant differences. However, Table 1 indicates a significant reduction in the quality control time of ICU nurses following the implementation of the system. Additionally, there was a notable enhancement in patient vital signs, medication management, and missed assessments compared to the period before the system was utilized. Table 1 A comparison of the quality control time and content of ICU nursing electronic medical records before and after implementation.(N = 600) Characteristics of patients Before implementation (n = 300) After implementation (n = 300) Statistical values P-value Gender(%) Female 130(43.33) 122(40.67) 0.438 a 0.508 Male 170(56.67) 178(59.33) Disease diagnoses(%) Cardiac disease 208(69.33) 210(70.00) 2.498 a 0.645 Disease of the digestive system 28(9.33) 29(9.67) Orthopedic disease 4(1.33) 8(2.66) Disease of the Nervous system 19(6.33) 13(4.33) Other diagnostic types of disease 41(13.67) 40(13.33) Length of stay in ICU[M(P25,P75),day] 5(7,10) 5(7,10) 18191.5 b 0.623 The quality control time[M(P25,P75),second] 264(195.5, 337.5) 62(48, 76) 45150 b <0.001 False data on vital signs in EMRs(%) YES 27(9.00) 4(1.33) 261.231 a <0.001 No 273(91.00) 296(98.67) Medication not administered to completion in EMRs(%) YES 10(3.33) 5(1.67) 275.339 a <0.001 No 290(96.67) 295(98.33) Missing evaluations of assessment items in EMRs(%) YES 24(8.00) 4(1.33) 264.229 a <0.001 No 276(92.00) 296(98.67) Note:EMRs:electronic medical records;a: Statistic value of the χ2 test;b: Wilcoxon rank-sum test; In this research, a total of 48 satisfaction surveys were gathered from the quality control system of the ICU nursing EMRs. Four surveys were deemed invalid and excluded, resulting in 44 valid surveys. The recovery rate of valid surveys was 91.67%. Based on the data presented in Table 2 , it is evident that the ICU nurses express a relatively high level of satisfaction with this system, as indicated by an overall satisfaction score of (105.73 ± 9.31). Table 2 The score of ICU nurse satisfaction scores for nursing EMR quality control system Variable Common nursing M(SD) Total satisfaction 105.73(9.31) system quality 18.23(2.05) information quality 22.89(2.47) service quality 18.25(2.07) user satisfaction 23.61(1.91) net benefits 22.75(2.60) Note:EMRs:electronic medical records. Discussion ICU nurses are required to dedicate a greater amount of time and effort to patient care compared to those working in standard hospital wards, particularly for patients undergoing prolonged mechanical ventilation and suffering from infections. Studies (11–12)have indicated that nurse-patient interactions and the complexities involved in delivering care are the primary obstacles in assessing the workload of ICU nurses. Additionally, the heightened demand for patient care services may impact the allocation of time for individual patient care by ICU nurses. In our study, we found that after the implementation of the electronic medical record quality control system for ICU nurses, time spent on quality control by these nurses decreased from 264(195.5, 337.5) seconds to 62(48, 76) seconds. The conventional manual quality control method is constrained by objective conditions and manpower, resulting in a substantial amount of time required for ICU quality control nurses to conduct quality control checks on the electronic medical records of all patients in the department. In our department, when the beds are at full capacity, the ICU quality control nurse must review 23 medical records, which, according to our study, takes at least 6072 seconds. The duration allows ICU nurses to administer nursing care to patients and execute nursing procedures such as repositioning, back patting, and rehabilitation exercises. Furthermore, the quality control results may be influenced by subjective factors of ICU quality control nurses, leading to potential deviations and challenges in ensuring the accuracy of nursing electronic medical records. In this study, an ICU nursing electronic medical record quality control system was developed using data platform integration technology. This system captures real-time data and offers automatic reminders based on predefined rules. Consequently, the time dedicated to manual inspection and omission evaluation by nurses was significantly reduced, resulting in improved work efficiency(13). The findings in Table 1 indicate that following the implementation of the ICU electronic medical record quality control system, there was a significant reduction in the prevalence of inaccurate vital sign data in the ICU electronic medical records, from 9–1.33%. Additionally, there was a decrease in medication administration compliance rates from 3.33–1.67%, and assessment completion rates decreased from 8–1.33%.The outcome may be attributed to the electronic medical record quality control system, which has the capability to capture real-time data and provide timely reminders for non-standard data and missed assessment items. This facilitates the identification of omissions in nursing electronic medical records by ICU nurses, enabling them to promptly rectify any gaps and reduce the incidence of missed assessments. Additionally, the quality control system can detect and correct false data in a timely manner, ensuring the authenticity and standardization of patient vital sign data. The satisfaction of healthcare professionals with electronic medical records is a significant factor in determining the quality of health information systems(14). In this study, the satisfaction score of ICU nurses with the quality control system for nursing EMRs is (105.73 ± 9.31), which is at a relatively high level, similar to the results of Zhang(15)'s study. Among the five dimensions of the evaluation scale for the effectiveness of clinical nursing information systems, user satisfaction and information quality, as well as net benefits, scored relatively high. The analysis suggests that this may be related to the increased acceptance of nursing information technology by ICU nurses. The use of the nursing electronic medical record quality control system can not only improve the standardization of electronic medical record writing, but also reduce the time spent on medical record quality control. The interactive feedback between the system and the nurses can also promote the nurses' awareness of the standardization of electronic medical records. Limitations The limitations of our study must be considered when interpreting our results.The electronic medical record quality control system for ICU care was developed with reference to our established EMR environment. As a result, it is difficult to generalize our findings directly to ICUs in other hospitals, which may limit generalizability. Conclusion We have designed and implemented an electronic medical record quality control system for ICU nursing in the clinical setting. This has resulted in a reduction in the time required for ICU nurses to review and control the quality of electronic medical records, as well as an overall improvement in the quality of the records. The system has been well-received by ICU nurses. Declarations Ethical considerations Zhejiang Provincial People's Hospital's Medical Ethics Committee approved this study before distribution of the questionnaire. Besides, These questionnaires were completed voluntarily by all nurses enrolled in this study. They were informed of the study's purpose and no negative effects were observed . We took all necessary steps to ensure the confidentiality and anonymity of the date . Consent for publication Not applicable Availability of data and materials If reasonable requests can be made, the corresponding author will provide access to the datasets used and/or analyzed during this study . Competing interests The authors declare that they have no competing interests. Funding This work was supported by Zhejiang Medical and Health Science and Technology Project (2021PY003). Authors' contributions ZS carried out the study, participated in collecting data, and drafted the manuscript. And ZS performed the statistical analysis and participated in its design. QYY and ZS participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript. Acknowledgements Thank “Home for Researchers editorial team ( www.home-for-researchers.com) References Liu 1LX, Zhao H, Zhang X, Xing G. Automatic approach for constructing a knowledge graph of knee osteoarthritis in Chinese. Health Inf Sci Syst. 2020;8(1):12. 10.1007/s13755-020-0102-4 . Published 2020 Feb 27. Shanbehzadeh 2SM, Nassari M, Kazemi-Arpanahi Z. H. Development and evaluation of an electronic nursing documentation system. BMC Nurs. 2022;21(1):15. Published 2022 Jan 10. 10.1186/s12912-021-00790-1 . Mensah 3GA, Oduro KA, Donkor G, Mock P. Barriers and facilitators to electronic medical records usage in the Emergency Centre at Komfo Anokye Teaching Hospital, Kumasi-Ghana. Afr J Emerg Med. 2017;7:177–82. 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Cite Share Download PDF Status: Published Journal Publication published 18 Jul, 2024 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 15 Mar, 2024 Reviews received at journal 12 Mar, 2024 Reviews received at journal 29 Feb, 2024 Reviewers agreed at journal 21 Feb, 2024 Reviewers agreed at journal 19 Feb, 2024 Reviewers invited by journal 19 Feb, 2024 Editor assigned by journal 30 Jan, 2024 Submission checks completed at journal 30 Jan, 2024 First submitted to journal 29 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3908730","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270031347,"identity":"e5dffb49-129b-4723-ba80-db40767efb21","order_by":0,"name":"Shuai 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College）","correspondingAuthor":false,"prefix":"","firstName":"Yin","middleName":"yin","lastName":"Quan","suffix":""},{"id":270031349,"identity":"8b4aa451-9ac0-4bbd-8dd3-ea6b5009673a","order_by":2,"name":"Juanhong Chen","email":"","orcid":"","institution":"Zhejiang Provincial People's Hospital （Affiliated People's Hospital, Hangzhou Medical College）","correspondingAuthor":false,"prefix":"","firstName":"Juanhong","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-01-29 10:49:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3908730/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3908730/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-024-02178-3","type":"published","date":"2024-07-18T16:13:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50509436,"identity":"67f5b8bc-74be-4956-9437-00c947dd4aad","added_by":"auto","created_at":"2024-02-01 16:00:20","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":342903,"visible":true,"origin":"","legend":"\u003cp\u003eICU nursing electronic medical record is linked with the monitor, real-time receiving patients' vital signs data.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3908730/v1/22d6b49655b8d28d79310dbb.jpeg"},{"id":50509438,"identity":"b0af6962-ca8f-4e3e-b3cd-00adcf6c694e","added_by":"auto","created_at":"2024-02-01 16:00:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13255,"visible":true,"origin":"","legend":"\u003cp\u003eReminder of pseudo data in the vital signs column.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3908730/v1/8d4ba2901c1ed22f8516f15e.png"},{"id":50509437,"identity":"228c2495-733f-4484-865c-1f061cae5f8c","added_by":"auto","created_at":"2024-02-01 16:00:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4079,"visible":true,"origin":"","legend":"\u003cp\u003eThe medication management column has not been executed.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3908730/v1/69726e396f78949cc08f7f71.png"},{"id":50509439,"identity":"9dfeddf7-e3e8-4576-8753-a71f9bdd53b1","added_by":"auto","created_at":"2024-02-01 16:00:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":76342,"visible":true,"origin":"","legend":"\u003cp\u003eReminder of missing assessment items in the patient assessment column\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3908730/v1/9eea2322be849357d76a46ba.png"},{"id":61595337,"identity":"9d66d89a-9506-46cb-bc6b-eefa5612cf41","added_by":"auto","created_at":"2024-08-01 17:22:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":802111,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3908730/v1/538b3607-b2d3-44d5-803e-0107bc86dfb4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Construction and application of ICU nursing electronic medical record quality control system","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIt has become widely popular to use electronic medical records(EMRs) due to the development of medical informatization(1).Nursing electronic medical record is an important part of the hospital information system, and its quality reflects the nursing quality and management level of medical institutions. EMRs and electronic clinical nursing documentation lead to greater quality, greater completeness, and more patient-centered documentation compared to manual nursing documentation(2).Improvements in patient care can be accelerated with an electronic medical record(3).The National Health Commission of the People's Republic of China released the \"Grading Evaluation Standards for the Application Level of Electronic Medical Record Systems\" in December 2018. In the six-level electronic medical record standard, it is mentioned that each medical service project should have the functions of process data collection, recording, and sharing. It should be able to display the entire process status and provide real-time data verification, prompts, and control functions based on the knowledge base for this link(4).\u003c/p\u003e \u003cp\u003eIn addition, the National Health Commission issued the Action Plan for Further Improving Nursing Services (2023\u0026ndash;2025) in June 2023, which mentioned that it is necessary to improve the quality of nursing and make full use of information technology to reduce the unnecessary writing burden of clinical nursing, so that nurses have more time to stay close to the clinic and provide direct nursing services to patients(5). In the intensive care unit(ICU), patients are continuously monitored, resulting in huge datasets(6). A large and complex amount of data is recorded in the ICU's EMRs, which undoubtedly increases the nursing workload(7). There is a growing body of evidence suggesting that EMRs integrated with ICU information systems lead to lower in-hospital mortality (8). In addition to providing intensive nursing care to critically ill patients, ICU nurses are also responsible for documenting standardized electronic medical records. This includes recording vital signs, nursing interventions, medication administration, and pipeline assessments on an hourly basis. With the widespread adoption of information technology, ICU wards in China have successfully integrated monitor and ventilator data with electronic medical records, allowing for real-time capture of data throughout the entire duration of care. Currently, if the patient exhibits actions such as coughing or rolling over, or other human-related factors, the vital signs column of the nursing electronic medical record may contain pseudo-data. Furthermore, ICU nurses may be occupied with attending to critically ill patients, potentially leading to overlooked assessments of pain, nutritional tolerance, restraints, and other conditions.\u003c/p\u003e \u003cp\u003eAt present, the quality control of nursing electronic medical records in many hospitals in China is still dominated by manual spot checks, and the automatic monitoring of electronic medical records has not yet been popularized(9).Moreover, the conventional quality control method for electronic medical records often involves manual verification, which is known for being time-consuming, prone to high omission rates, and subject to significant subjectivity. Since March 2020, our hospital has relied on the hospital information system and in accordance with the core requirements of the National Health Commission's Level 6 electronic medical record application, and successfully passed the National Health Commission's Level 6 electronic medical record assessment in July 2023. In the intensive care unit (ICU), the nurse utilizes the wireless network to connect the monitor, ventilator, and ICU nursing electronic medical record system. This allows for the real-time collection, transmission, and recording of the patient's vital signs, thus minimizing errors associated with manual recording. Furthermore, ICU nurses are able to scan the barcode on the drug execution form using their personal digital assistant (PDA), enabling them to initiate, adjust, and terminate drug administration within the ICU nursing electronic medical record system. This implementation facilitates closed-loop drug management. Despite the convenience of the ICU nursing electronic medical record system for ICU nurses, issues persist including inaccurate data, delayed administration of medications, and incomplete evaluation management. As a result, it has been decided to assign a nurse to conduct daily quality control of ICU nursing electronic medical records. Based on this background, this study successfully implemented an ICU nursing electronic medical record quality control system in clinical practice, aiming to provide ICU nurses with more time to focus on patient care and reduce the time spent on medical record documentation and quality control. The results of this implementation were found to be positive.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The study was conducted in the ICU of a tertiary hospital in Zhejiang Province, China, in a single-center, prospective controlled study .The study involved a sample of 600 patients who were admitted to the intensive care unit (ICU) of a tertiary hospital in Zhejiang Province between January and December 2023.\u003c/p\u003e \u003cp\u003eICU nursing electronic medical records quality control (QC)was performed manually before June 2023. QC nurses will periodically check the electronic medical record based on the prescription on a daily basi. As part of tertiary care requirements, nurses are required to record the patient's vital signs, including monitor and ventilator parameters, every hour in their nursing electronic medical record. In cases of change in condition, the recording frequency should be increased. We have implemented a nursing electronic medical record system that is wirelessly connected to monitors, ventilators, and other instruments in our ICU.This ensures that the patient's vital signs are captured and recorded in the nursing electronic medical record(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For example, if patient A is mechanically ventilated, the electronic medical record system will collect vital signs from 1AM-12PM. When there is a change in condition, it can also separately capture vital signs per minute, such as heart rate, blood pressure, ventilator tidal volume, etc. ICU QC nurses can check the curve of vital signs in the nursing electronic medical record, and find pseudo-data with the naked eye to make artificial manual modifications. In terms of drug administration, our hospital has implemented closed-loop management of drugs.ICU nurses use Personal Digital Assistant (PDA) to scan Quick Response (QR) codes on drugs to start and end operations. Nevertheless, there may be a situation where the medication is not terminated due to problems such as a malfunctioning network or PDA. Therefore, ICU QC nurses will artificially end the medication, thus creating a closed-loop management of the medication. In addition, ICU nurses are required to assess patients for physical restraints, medication sedation, mental status, and nutritional scores as required. If there are omissions, they are also added manually by the ICU QC nurse.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn this study, a research team was formed to investigate the quality control of electronic medical records (EMRs) in the Intensive Care Unit (ICU). The team consists of 3 members, including 1 ICU nurse leader A with a senior professional title, 1 nurse B with a master's degree, and 1 information engineer C. A is responsible for the content scheme construction of the nursing electronic medical record quality control system, B is responsible for reviewing literature and subsequent data collection and statistical analysis, and C is responsible for the construction of the system and technical maintenance during the use process. The team utilized the ICU nursing EMR system as a foundation and employed group brainstorming techniques to design quality control rules for the EMRs. Additionally, the team collaborated with information engineers to construct an ICU nursing EMR quality control system. This system enables real-time data collection and facilitates quality control measures for patient vital signs, medication management, nursing evaluation, and shift handover. Furthermore, the system incorporates dynamic reminders and ensures the quality control of electronic medical records.\u003c/p\u003e \u003cp\u003eThe ICU nursing electronic medical record quality control module mainly includes three parts: \u003cb\u003evital signs, drug management, and evaluation management\u003c/b\u003e. \u003cb\u003eThe vital signs\u003c/b\u003e section requires hourly records of the patient's heart rate, oxygen saturation, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and respiration. The patient's body temperature must be measured every 4 hours, specifically at 6:00, 10:00, 14:00, 18:00, 20:00, and 24:00. If the patient is on a ventilator, the vital signs section should also be recorded on an hourly basis, such as respiratory rate, minute ventilation, inhaled tidal volume, exhaled tidal volume, and oxygen concentration. If the above data is missing, the system will remind the nurse to supplement it in time. In addition, if there is an abnormal value in the data collected by the electronic medical record system, such as an exhaled tidal volume of \u0026lt;\u0026thinsp;150ml, an alert will be given(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The nurse will make timely corrections according to the reminder to ensure the accuracy of the data. \u003cb\u003eThe drug management\u003c/b\u003e part requires strict implementation in accordance with the doctor's instructions. When the micropump injection drug is executed, the infusion speed will be requested, and the medical record quality control system will remind the drug end time according to the set drug speed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). \u003cb\u003eAssessment management\u003c/b\u003e content and assessment frequency in the electronic medical records of ICU nursing are as follows: Patient position, need for physical restraint to be assessed every 2 hours; skin condition, level of consciousness, pupil size (left/right), upper limb muscle strength (left/right), lower limb muscle strength (left/right), breath sounds, sputum viscosity and volume, urine color, bowel sounds, dorsalis pedis artery pulse (left/right), lower limb edema (left/right), delirium assessment, high-risk pressure injury assessment, pain assessment, Glasgow Coma Scale, and enteral nutrition intolerance assessment to be assessed every 4 hours. If the nurse does not assess within the specified time, the system will pop up a reminder box(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Once the ICU nurse completes the assessment in a timely manner, the reminder box will disappear.\u003c/p\u003e \u003cp\u003eThe implementation of the ICU nursing electronic medical record quality control system commenced in July 2023. A comparison was made between the time spent by nurses on medical record quality control before the system's implementation (January to June 2023) and after its implementation (July to December 2023). Additionally, the study examined the nurses' satisfaction with the system, as well as the patient vital signs, medication management, and evaluation management in nursing EMRs.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDate collection\u003c/h2\u003e \u003cp\u003eIn this research, a total of 300 nursing electronic medical records were randomly chosen to undergo manual quality control assessment prior to the implementation of the ICU nursing electronic medical record quality control system (January to June 2023). The manual quality control assessment team comprised five ICU nurses, all holding the position of head nurse. Each nurse was tasked with reviewing 10 different nursing electronic medical records every months, focusing on vital signs, medications, and assessment management sections from the previous 24 hours. The time taken for each record inspection was recorded, from the start to the end of the inspection. Subsequently, following the introduction of the ICU nursing electronic medical record quality control system (July to December 2023), another 300 nursing electronic medical records were randomly chosen for electronic quality control assessment. Similarly, each of the five nurses randomly selected 10 nursing electronic medical records for inspection every months. The nurses utilized the quality control system to prompt them to review the nursing electronic medical records from the previous 24 hours, and the time taken for each electronic medical record inspection was recorded. The inclusion criteria for the selected medical records were patients over 18 years old who had stayed in the ICU for longer than 24 hours.\u003c/p\u003e \u003cp\u003eThe study utilized the clinical nursing information system effectiveness evaluation scale developed by Zhao(10)to assess nurses' satisfaction with the restraint management system. This scale comprises five dimensions: system quality, information quality, service quality, user satisfaction, and net benefits, with a total of 23 items. Each item is rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The total score ranges from 23 to 115, with a higher score indicating greater satisfaction with the management system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThis study used R version 3.5.3 to analyze the data in this study. Means and standard deviations for metrics with normally distributed data were analyzed using t-tests, while medians and quartile were used for metrics with non-normal distributions .Analyses were conducted using the non-parametric test, and counts were described by frequency and percentage using the χ2 test.An analysis with a p-value of 0.05 was considered statistically significant .\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePrior to and subsequent to the implementation of the ICU nursing EMR quality control system, 300 patient cases were analyzed to compare gender, disease diagnosis, and length of ICU stay. The results showed no statistically significant differences. However, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e indicates a significant reduction in the quality control time of ICU nurses following the implementation of the system. Additionally, there was a notable enhancement in patient vital signs, medication management, and missed assessments compared to the period before the system was utilized.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA comparison of the quality control time and content of ICU nursing electronic medical records before and after implementation.(N\u0026thinsp;=\u0026thinsp;600)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore implementation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;300)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter implementation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;300)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStatistical values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130(43.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122(40.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.438\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170(56.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e178(59.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eDisease diagnoses(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiac disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208(69.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e210(70.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e2.498\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisease of the digestive system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(9.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29(9.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopedic disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(2.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisease of the Nervous system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(6.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(4.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther diagnostic types of disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(13.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40(13.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLength of stay in ICU[M(P25,P75),day]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(7,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(7,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18191.5\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.623\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eThe quality control time[M(P25,P75),second]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e264(195.5, 337.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62(48, 76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45150\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFalse data on vital signs in EMRs(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(9.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e261.231\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e273(91.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e296(98.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMedication not administered to completion in EMRs(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e275.339\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e290(96.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e295(98.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMissing evaluations of assessment items\u003c/p\u003e \u003cp\u003ein EMRs(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(8.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e264.229\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276(92.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e296(98.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote:EMRs:electronic medical records;a: Statistic value of the χ2 test;b: Wilcoxon rank-sum test;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this research, a total of 48 satisfaction surveys were gathered from the quality control system of the ICU nursing EMRs. Four surveys were deemed invalid and excluded, resulting in 44 valid surveys. The recovery rate of valid surveys was 91.67%. Based on the data presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, it is evident that the ICU nurses express a relatively high level of satisfaction with this system, as indicated by an overall satisfaction score of (105.73\u0026thinsp;\u0026plusmn;\u0026thinsp;9.31).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe score of ICU nurse satisfaction scores for nursing EMR quality control system\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommon nursing\u003c/p\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e105.73(9.31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esystem quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.23(2.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einformation quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.89(2.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eservice quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.25(2.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003euser satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.61(1.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enet benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.75(2.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote:EMRs:electronic medical records.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eICU nurses are required to dedicate a greater amount of time and effort to patient care compared to those working in standard hospital wards, particularly for patients undergoing prolonged mechanical ventilation and suffering from infections. Studies (11\u0026ndash;12)have indicated that nurse-patient interactions and the complexities involved in delivering care are the primary obstacles in assessing the workload of ICU nurses. Additionally, the heightened demand for patient care services may impact the allocation of time for individual patient care by ICU nurses. In our study, we found that after the implementation of the electronic medical record quality control system for ICU nurses, time spent on quality control by these nurses decreased from 264(195.5, 337.5) seconds to 62(48, 76) seconds. The conventional manual quality control method is constrained by objective conditions and manpower, resulting in a substantial amount of time required for ICU quality control nurses to conduct quality control checks on the electronic medical records of all patients in the department. In our department, when the beds are at full capacity, the ICU quality control nurse must review 23 medical records, which, according to our study, takes at least 6072 seconds. The duration allows ICU nurses to administer nursing care to patients and execute nursing procedures such as repositioning, back patting, and rehabilitation exercises. Furthermore, the quality control results may be influenced by subjective factors of ICU quality control nurses, leading to potential deviations and challenges in ensuring the accuracy of nursing electronic medical records. In this study, an ICU nursing electronic medical record quality control system was developed using data platform integration technology. This system captures real-time data and offers automatic reminders based on predefined rules. Consequently, the time dedicated to manual inspection and omission evaluation by nurses was significantly reduced, resulting in improved work efficiency(13).\u003c/p\u003e \u003cp\u003eThe findings in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e indicate that following the implementation of the ICU electronic medical record quality control system, there was a significant reduction in the prevalence of inaccurate vital sign data in the ICU electronic medical records, from 9\u0026ndash;1.33%. Additionally, there was a decrease in medication administration compliance rates from 3.33\u0026ndash;1.67%, and assessment completion rates decreased from 8\u0026ndash;1.33%.The outcome may be attributed to the electronic medical record quality control system, which has the capability to capture real-time data and provide timely reminders for non-standard data and missed assessment items. This facilitates the identification of omissions in nursing electronic medical records by ICU nurses, enabling them to promptly rectify any gaps and reduce the incidence of missed assessments. Additionally, the quality control system can detect and correct false data in a timely manner, ensuring the authenticity and standardization of patient vital sign data.\u003c/p\u003e \u003cp\u003eThe satisfaction of healthcare professionals with electronic medical records is a significant factor in determining the quality of health information systems(14). In this study, the satisfaction score of ICU nurses with the quality control system for nursing EMRs is (105.73\u0026thinsp;\u0026plusmn;\u0026thinsp;9.31), which is at a relatively high level, similar to the results of Zhang(15)'s study. Among the five dimensions of the evaluation scale for the effectiveness of clinical nursing information systems, user satisfaction and information quality, as well as net benefits, scored relatively high. The analysis suggests that this may be related to the increased acceptance of nursing information technology by ICU nurses. The use of the nursing electronic medical record quality control system can not only improve the standardization of electronic medical record writing, but also reduce the time spent on medical record quality control. The interactive feedback between the system and the nurses can also promote the nurses' awareness of the standardization of electronic medical records.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThe limitations of our study must be considered when interpreting our results.The electronic medical record quality control system for ICU care was developed with reference to our established EMR environment. As a result, it is difficult to generalize our findings directly to ICUs in other hospitals, which may limit generalizability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe have designed and implemented an electronic medical record quality control system for ICU nursing in the clinical setting. This has resulted in a reduction in the time required for ICU nurses to review and control the quality of electronic medical records, as well as an overall improvement in the quality of the records. The system has been well-received by ICU nurses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical considerations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhejiang Provincial People\u0026apos;s Hospital\u0026apos;s Medical Ethics Committee approved this study before distribution of the questionnaire. Besides, These questionnaires were completed voluntarily by all nurses enrolled in this study. They were informed of the study\u0026apos;s purpose and no negative effects were observed . We took all necessary steps to ensure the confidentiality and anonymity of the date .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIf reasonable requests can be made, the corresponding author will provide access to the datasets used and/or analyzed during this study .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Zhejiang Medical and Health Science and Technology Project (2021PY003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZS carried out the study, participated in collecting data, and drafted the manuscript. And ZS performed the statistical analysis and participated in its design. QYY and ZS participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank \u0026ldquo;Home for Researchers editorial team ( www.home-for-researchers.com)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiu 1LX, Zhao H, Zhang X, Xing G. Automatic approach for constructing a knowledge graph of knee osteoarthritis in Chinese. Health Inf Sci Syst. 2020;8(1):12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s13755-020-0102-4\u003c/span\u003e\u003cspan address=\"10.1007/s13755-020-0102-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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ZQ,Optimization and Effect Analysis of Quality Control System of Nursing Electronic Medical Records[J]. Hosp Adm Forum 2021,38(8):85\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebremariam 14BM, Berhe K. G, Evaluation of electronic medical record implementation from user\u0026rsquo;s perspectives in Ayder referral hospital Ethiopia[J]. 2017,8(1):2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShuai 15ZHANG, Juanhong CHEN, Yinyin QUAN, Huiping YAO. Construction and application of a physical restraint management system for ICU patients[J]. Chin J Nurs. 2023;58(1):55\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intensive Care Units, Digitalization of nursing, Electronic medical record, Nursing quality control","lastPublishedDoi":"10.21203/rs.3.rs-3908730/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3908730/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn addition to providing intensive nursing care to critically ill patients, ICU nurses are also responsible for documenting standardized electronic medical records. This includes recording vital signs, nursing interventions, medication administration, and pipeline assessments on an hourly basis. With the widespread adoption of information technology, ICU wards in China have successfully integrated monitor and ventilator data with electronic medical records, allowing for real-time capture of data throughout the entire duration of care. Currently, if the patient exhibits actions such as coughing or rolling over, or other human-related factors, the vital signs column of the nursing electronic medical record may contain pseudo-data. Furthermore, ICU nurses may be occupied with attending to critically ill patients, potentially leading to overlooked assessments of pain, nutritional tolerance, restraints, and other conditions. Moreover, the conventional quality control method for electronic medical records often involves manual verification, which is known for being time-consuming, prone to high omission rates, and subject to significant subjectivity. Furthermore, the transmission of crucial information by doctors to the succeeding shift nurses often takes the form of verbal handover, which frequently results in omissions or deviations, thereby compromising the accuracy of the shift handover. Consequently, there is an imperative requirement to enhance the standardization rate of electronic medical records in ICU nursing and improve the accuracy of handover through the utilization of information technology.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjective:The purpose of this study is to develop a quality control system for electronic medical records in ICU nursing and investigate its impact on clinical practice.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDesign:The design of this study is prospective controlled trial.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn this study, a research team was formed to investigate the quality control of electronic medical records (EMRs) in the Intensive Care Unit (ICU). The team utilized the ICU nursing EMR system as a foundation and employed group brainstorming techniques to design quality control rules for the EMRs. Additionally, the team collaborated with information engineers to construct an ICU nursing EMR quality control system. This system enables real-time data collection and facilitates quality control measures for patient vital signs, medication management, nursing evaluation, and shift handover. Furthermore, the system incorporates dynamic reminders and ensures the quality control of electronic medical records. The study involved a sample of 120 patients who were admitted to the intensive care unit (ICU) of a tertiary hospital in Zhejiang Province between January and December 2023. The implementation of the ICU nursing electronic medical record quality control system commenced in July 2023. A comparison was made between the time spent by nurses on medical record quality control before the system's implementation (January to June 2023) and after its implementation (July to December 2023). Additionally, the study examined the nurses' satisfaction with the system, as well as the total missed rate of nursing evaluation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAfter the use of the ICU nursing electronic medical record quality control system, there was a significant reduction in the prevalence of inaccurate vital signs in the ICU EMRs, from 9% to 1.33%. Additionally, there was a decrease in medication administration compliance rates from 3.33% to 1.67%, and assessment completion rates decreased from 8% to 1.33%. Besides, the average electronic medical record quality control time spent per electronic medical record was 62(48,76) seconds, which was significantly lower than the traditional quality control time spent in 264(195.5,337.5)seconds. The nurses' satisfaction with the nursing electronic medical record quality control was (105.73±9.31).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusions:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe ICU nursing electronic medical record quality control system can reduce the time spent by nurses on the quality control of nursing electronic medical records, improve the satisfaction of nurses with the quality control of nursing electronic medical records, and significantly reduce the rate of missed evaluation of nurses in ICU nursing documents through this system.\u003c/em\u003e\u003c/p\u003e","manuscriptTitle":"Construction and application of ICU nursing electronic medical record quality control system","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-01 16:00:15","doi":"10.21203/rs.3.rs-3908730/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-15T09:36:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-12T22:14:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-29T19:19:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44d8cd21-4054-4e88-a48b-7021d40a3b18","date":"2024-02-22T00:34:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94172ec6-ad37-45f5-8452-0311fc0f02b1","date":"2024-02-19T22:21:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-19T21:44:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-30T12:11:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-30T12:07:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2024-01-29T10:30:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4716aa6c-fa89-4bf5-b188-58e5ad9bc7d5","owner":[],"postedDate":"February 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T16:21:15+00:00","versionOfRecord":{"articleIdentity":"rs-3908730","link":"https://doi.org/10.1186/s12912-024-02178-3","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2024-07-18 16:13:26","publishedOnDateReadable":"July 18th, 2024"},"versionCreatedAt":"2024-02-01 16:00:15","video":"","vorDoi":"10.1186/s12912-024-02178-3","vorDoiUrl":"https://doi.org/10.1186/s12912-024-02178-3","workflowStages":[]},"version":"v1","identity":"rs-3908730","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3908730","identity":"rs-3908730","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}