JMIR Publications

ABSTRACT

Background:

A completed documentation of critical care events in the Accident and Emergency Department (AED) is essential. Due to the fast-paced and complex nature of resuscitation cases, missing data is a common issue during emergency situations.

Objective:

To evaluate the impact of a tablet-based resuscitation record on documentation completeness during medical resuscitations and nurses’ perception on the use of the tablet application.

Methods:

A mixed method approach was adopted. For the quantitative data, randomised retrospective reviews of paper resuscitation records before (Pre-App Paper) (n=176), after implementation of the tablet resuscitation paper records (Post-App Paper) (n=176), and tablet-based resuscitation electronic records (Post-App Electronic) (n=176) against a documentation completeness checklist was conducted. The checklist consists of five domains: basic information, vital signs, procedures, investigations and medications. For the qualitative data, nurses’ perception towards the application of electronic resuscitation documentation was obtained using individual interviews.

Results:

Post-App Electronic had significantly higher completion rate than Post-App Paper in all five domains (i.e., basic information, vital signs, procedures, investigations, and medications); but no significant differences between Pre-App and Post-App Paper in five domains. For the qualitative side, the main category identified were: ‘Advantages of tablet resuscitation record in documentation’, ‘Challenges of tablet resuscitation record in documentation’, and ‘Areas for improvement in tablet resuscitation record’.

Conclusions:

This study demonstrated that tablet-based resuscitation electronic records have higher completion rate compared to traditional paper records. Nurses should provide feedbacks on the application’s usability and functionality during application refinement to ensure success in the transition and future development of electronic documentation record.