Diagnosis Documentation of Critically Ill Children at Admission to a PICU.

Objectives: Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission.
Design: Retrospective mixed methods study describing diagnosis documentation in electronic health records.
Setting: Academic tertiary referral PICU.
Patients: Children 0-17 years old admitted nonelectively to a single PICU over 1 year.
Interventions: None.
Measurements and Main Results: One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty.
Conclusions: In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
Competing Interests: Drs. Vivtcharenko’s, Dukes’, Herwaldt's, Reisinger's, and Cifra’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ), the National Institute of Child Health and Human Development, and the National Center for Advancing Translational Sciences. Dr. Cifra is supported by the AHRQ through a K08 grant (HS026965) and an internal start-up grant from the University of Iowa Carver College of Medicine Department of Pediatrics. Dr. Singh disclosed government work. He is supported by the Veterans Affairs Health Services Research and Development Service (Presidential Early Career Award for Scientists and Engineers USA 14-274), the Agency for Health Care Research and Quality (R01HS022087), the Gordon and Betty Moore Foundation, and the Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (Center for Innovations 13–413). Dr. Herwaldt’s institution received funding from the Centers for Disease Control and Prevention, the AHRQ, and PDI. Dr. Reisinger is supported by an NIH Clinical and Translational Science Award (UL1TR002537) through the University of Iowa’s Institute for Clinical and Translational Science. Dr. Cifra received funding from AHRQ. Dr. Ramesh has disclosed that she does not have any potential conflicts of interest.
(Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)