RESUMO
BACKGROUND: ICU nurses provide critical care and meticulously document electronic medical records (EMRs), tracking vital signs, interventions, and medication hourly. Despite China's ICUs effectively integrating real-time monitor and ventilator data into EMRs, challenges persist. Patient movements can introduce inaccuracies, and the demands of critical care may lead nurses to miss assessments like pain and nutrition. Traditional manual EMR verification is inefficient and error-prone, highlighting the urgent need for standardized, technology-aided EMR practices in ICU nursing. OBJECTIVE: This study aimed to describe the development and evaluation of an electronic medical records quality control system implemented in a Chinese tertiary care ICU setting, where current practices impact the accuracy of electronic medical records. METHODS: A prospective controlled trial was conducted with 600 ICU patients in Zhejiang Province from January to December 2023. An automated EMR quality control system was implemented in July 2023, facilitating real-time data collection and quality control for vital signs, medication management, and nursing evaluations. RESULTS: After implementing the ICU nursing electronic medical record quality control system, the prevalence of false data on vital signs decreased from 9 to 1.33%. Additionally, the incidence of incomplete medication administration dropped from 3.33 to 1.67%, and the rate of missing evaluations of assessment items in EMRs was reduced from 8 to 1.33%. Besides, the average time spent on quality control of the electronic medical records was 62 (48,76) seconds per record, which was significantly lower than the 264 (195.5,337.5) seconds using the traditional method. 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 has led to substantial improvements in the quality and reliability of EMRs. The reduction in false data on vital signs, instances of incomplete medication administration, and missing evaluations of assessment items demonstrates the system's positive impact on nursing documentation practices. These improvements not only enhance the accuracy of patient records but also contribute to better patient care and safety within the ICU setting.
