Resident documentation discrepancies in a neonatal intensive care unit.

摘要: Context. Medical errors are common and potentially dangerous. Little is known about the role of documentation errors. Objective. To determine proportion resident physician progress notes that contained discrepancies, to identify predictors such discrepancies. Design/Methods. We conducted a retrospective cross-sectional chart review over 40 random days in 4-month period neonatal intensive care unit. Using predetermined criteria, we compared patient weights, medications, vascular lines other sources information recorded numbers Results. There were discrepancies 209 (61.7%) with respect weight, lines, or medications. Discrepancies occurred medications 103 (27.7%) notes, 119 (33.9%) weights 45 (13.3%) notes. Notes both omitted regarding (18.2%) (13.9%) documented inaccurate (18.6%) (30.1%). Patients more longer lengths stay, significantly likely have higher rates Conclusions. Daily written by physicians unit often contain inaccurate, omit pertinent, information. Alternative means methods warranted.