A SURVEY OF CHARTING IN CRITICAL CARE UNITS

Objectives. To determine what data are currently being collected at the critical care bedside, the role of flow sheets in storing these data, and what other forms and locations are used to store critical care data. Design: We undertook a descriptive survey in a nonrandom sample of acute care hospitals with designated critical care units. Flow sheets were reviewed, and interviews with critical care nurses and physicians were conducted according to a predefined questionnaire. Finally, compliance in the surveyed hospitals with previous recommendations and existing guidelines on data collection and storage was then determined. Setting. Fifteen ''teaching'' and 19 ''nonteaching'' acute care hospitals in the Province of Ontario. Results: A lack of standardization of flow-sheet design and of the specific data included on these flow sheets was identified. Abbreviations were inconsistent. Little collaboration between physician and nonphysician members of the critical care team was identified in flow-sheet design. Variance between units in their collection of physiologic data was remarkable. Finally, few units surveyed used quantifiable illness severity scoring to describe their unit population. Conclusions. The lack of standardization regarding key information that should be collected and archived in critical care units identifies important risk management and quality assurance issues. There is a need for agreement on what information should be collected and maintained at the bedside in order to provide quality patient care.