Journal of the American Medical Informatics Association : JAMIA
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J Am Med Inform Assoc · Jan 2011
Agreement between common goals discussed and documented in the ICU.
Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. ⋯ The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.