Documentation of antimicrobial indication and duration in electronic health records in a rehabilitation hospital: a cross-sectional study

TL;DR

This study found that antimicrobial prescriptions in a rehabilitation hospital had poor documentation of reasons and duration, suggesting the need for system improvements.

Contribution

The study identifies gaps in antimicrobial documentation in a rehabilitation hospital and proposes practical solutions like reminders and system design changes.

Findings

Only 63% of antimicrobial prescriptions had complete documentation of indication.

Only 25% of prescriptions had complete documentation of duration.

Potential solutions include reminders, improved choice architecture, and forced functions.

Abstract

In this cross-sectional study of 136 antimicrobial prescriptions at a rehabilitation hospital with recent implementation of electronic medication order entry and no mandatory requirements, we found incomplete documentation of both indication (37%) and duration (75%). An accompanying survey identified potential solutions including reminders, improved choice architecture, and forced functions.

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