Resident Documentation Discrepancies in a Neonatal Intensive Care Unit

Abstract

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