The Impact of Hybridisation on the Accuracy of Fluid Balance Documentation: A Retrospective Cross-Sectional Analysis of Intravenous Fluid Order and Administration Documentation Using a Partly-Computerized Medical Record in an Australian Tertiary Teaching Hospital

摘要

Inaccurate intravenous (IV) fluid documentation remains a major cause of fluid-related adverse health outcomes in hospitals. In this study, we characterise the integrity and documentation completeness of a hybrid paper-computer documentation system for IV fluids and explore how inconsistencies within it are associated with adverse patient health outcomes. We highlight key areas of weakness specific to IV fluid documentation that need to be addressed in moving to a fully computerised system in the future.