Inadequate documentation of asthma management in hospitalized adult patients

Lori B. Arnold, Justin B. Usery, Christopher K. Finch, Jessica L. Wallace, Paul R. Deaton, Timothy Self

Research output: Contribution to journalReview article

7 Citations (Scopus)

Abstract

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.

Original languageEnglish (US)
Pages (from-to)510-514
Number of pages5
JournalSouthern medical journal
Volume102
Issue number5
DOIs
StatePublished - May 1 2009

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Documentation
Asthma
Medical Records
Adrenal Cortex Hormones
International Classification of Diseases
Education
Referral and Consultation
Quality of Health Care
Respiratory Tract Infections
Hospitalization
Cardiovascular Diseases
Smoking
History
Guidelines
Therapeutics

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

Arnold, L. B., Usery, J. B., Finch, C. K., Wallace, J. L., Deaton, P. R., & Self, T. (2009). Inadequate documentation of asthma management in hospitalized adult patients. Southern medical journal, 102(5), 510-514. https://doi.org/10.1097/SMJ.0b013e31819ecb03

Inadequate documentation of asthma management in hospitalized adult patients. / Arnold, Lori B.; Usery, Justin B.; Finch, Christopher K.; Wallace, Jessica L.; Deaton, Paul R.; Self, Timothy.

In: Southern medical journal, Vol. 102, No. 5, 01.05.2009, p. 510-514.

Research output: Contribution to journalReview article

Arnold, LB, Usery, JB, Finch, CK, Wallace, JL, Deaton, PR & Self, T 2009, 'Inadequate documentation of asthma management in hospitalized adult patients', Southern medical journal, vol. 102, no. 5, pp. 510-514. https://doi.org/10.1097/SMJ.0b013e31819ecb03
Arnold, Lori B. ; Usery, Justin B. ; Finch, Christopher K. ; Wallace, Jessica L. ; Deaton, Paul R. ; Self, Timothy. / Inadequate documentation of asthma management in hospitalized adult patients. In: Southern medical journal. 2009 ; Vol. 102, No. 5. pp. 510-514.
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