Documentation of contact precautions in an electronic health record

Abstract

Contact precautions are implemented to reduce transmission of multidrug-resistant organisms but may also increase hospital costs and patient complications. The goal of this study was to determine the prevalence of documentation of contact precautions (provider orders and nursing flowsheet documentation) in an electronic health record. Orders and nursing documentation were simultaneously present for only 42.3% of patient rooms with contact precaution signs, and 17.8% of rooms with signs had neither orders nor nursing documentation.

Figure

Nurses documented the continuation of all types of isolation precautions under the “Safety” section of the electronic nursing flowsheet. Contact precautions were indicated by selecting “Contact,” “Droplet/Contact,” or “Airborne/Contact,” or by typing “contact” into the free-text field.