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Diagnosis Documentation of Critically Ill Children at Admission to a PICU
Journal article   Peer reviewed

Diagnosis Documentation of Critically Ill Children at Admission to a PICU

Victoria Y Vivtcharenko, Sonali Ramesh, Kimberly C Dukes, Hardeep Singh, Loreen A Herwaldt, Heather Schacht Reisinger and Christina L Cifra
Pediatric critical care medicine, Vol.23(2), pp.99-108
02/01/2022
DOI: 10.1097/PCC.0000000000002812
PMCID: PMC8816809
PMID: 34534163

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Abstract

Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission. Retrospective mixed methods study describing diagnosis documentation in electronic health records. Academic tertiary referral PICU. Children 0-17 years old admitted nonelectively to a single PICU over 1 year. None. One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty. In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
 Adolescent Child Child, Preschool Critical Illness Documentation Hospitalization Humans Infant Infant, Newborn Intensive Care Units, Pediatric Retrospective Studies

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