Accuracy of Electronic Health Record Documentation of Parental Presence: A Data Validation and Quality Improvement Analysis.

ABSTRACT

Parental presence in the neonatal intensive care unit (NICU) is known to improve the health outcomes of an admitted infant. The use of the electronic health record (EHR) to analyze associations between parental presence and sociodemographic factors could provide important insights to families at greatest risk for limited presence during their infant's NICU stay, but there is little evidence about the accuracy of nonvital clinical measures such as parental presence in these datasets. A data validation study was conducted comparing the percentage agreement of an observational log of parental presence to the EHR documentation. Overall, high accuracy values were found when combining two methods of documentation. Additional stratification using a more specific measure, each chart's complete accuracy, instead of overall accuracy, revealed that night shift documentation was more accurate than day shift documentation (76.3% accurate during night shifts, 55.2% accurate during day shifts) and that flowsheet (FS) recordings were more accurate than the free-text plan of care (POC) notes (82.4% accurate for FS, 75.1% accurate for POC notes). This research provides a preliminary look at the accuracy of EHR documentation of nonclinical factors and can serve as a methodological roadmap for other researchers who intend to use EHR data.