PURPOSE:The medical record (MR) is the key source of data surrounding a patient's encounter with the health care system. Thus, undocumented patient information is a barrier to providing high quality care. This critical issue of inadequate documentation has recently been reported for two common cardiovascular diseases (Am J Med 2003). We evaluated the documentation of asthma management in the MR to determine if it is consistent with guidelines provided by the National Institutes of Health. We also assessed patient factors that contributed to admission and asthma regimens prior to admission, during hospitalization, and upon discharge.
METHODS:We performed a retrospective chart review of 207 admissions between January 1, 2004 and May 24, 2007 with an ICD-9 code, primary diagnosis of asthma. Inclusion criteria were ages 18–49, hospitalization for >24 hours, and <10 pack year smoking history.
RESULTS:Overall, most patients were African American (87%), inner-city, or low socioeconomic status. Upon discharge, 83% of patients had no documentation of asthma education. Furthermore, 97% lacked documentation of a written asthma action plan being given; 85% did not have referral to an allergist or pulmonologist. Respiratory infection was the most common factor associated with admission for asthma exacerbation; however, in 52% of admissions, the exacerbating factor was not documented. When assessing asthma regimens, only 47% of patients were receiving an inhaled corticosteroid (ICS) prior to admission, and 23% of patients did not have an ICS prescribed for maintenance therapy upon discharge.
CONCLUSION:Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Critical information such as the exacerbating factor was not documented in a majority of admissions. During hospitalization, almost all patients were receiving therapy consistent with national guidelines. Prior to admission and upon discharge, an inadequate number of patients were receiving an ICS as maintenance therapy.
CLINICAL IMPLICATIONS:Undocumented patient information in the MR is a significant issue. Mechanisms are needed to ensure appropriate documentation in the MR per national guidelines.
DISCLOSURE:Lori Arnold, No Financial Disclosure Information; No Product/Research Disclosure Information