Documentation of vital signs in electronic health records: issues for patient safety

Inadequate design and poor user-interface are given as reasons for unsuccessful implementation of electronic health records (EHR) [1,2]. However, rather than designing more suitable technology, the trend has been to 'muddle through' [2] and to urge health care workers to adapt to poorly designed systems [3]. This may work to some degree but little is known about the impact this could have on patient safety. The design of vital sign charts has an impact on the ability of clinicians to detect deterioration in patients' clinical status [4-6]. Changes in a patient's vital signs may indicate a lifethreatening event [7,8] so charts should be user-friendly to support clinicians in decision-making [9,10]. The aim of this study was to examine the documentation of physiological vital signs in an EHR. In this paper, we present the results regarding accessing information on a patient's physiological vital signs.