Background The electronic health record (EHR) includes all of the documents relating to healthcare processes for each patient, identifying doctors and other professionals who have participated in their care in order to obtain the maximum possible integration of clinical documentation. The main purpose is to provide healthcare, recording all data related to medical judgments, allowing accurate and updated knowledge of the patient’s health status.
Purpose To analyse anthropometric data required for clinical monitoring of the patient and establishment of drug doses, as well as influencing the calculation of clinical values (renal clearance, BMI or body surface).
Material and methods This was a cross sectional study in which all patients admitted to the hospital in a day were checked to see if they had their weight recorded in the EHR. We also checked if they were receiving drugs where it is recommended that doses are adjusted depending on weight.
Results Of 481 patients admitted in a day to our hospital, 112 did not have their weight recorded (23.28%). Of these, 70.6% had treatments which required dose adjustment based on weight, such as enoxaparin or other antibiotics.
Services with the highest percentage of weight recorded in the EHR were onco-haematology (96.3%), general surgery and digestive (92.59%), internal medicine (95%) and paediatrics (92.31%). Geriatrics had the least records of the weight of their patients (31.82%). It is particularly important in the geriatric population to record weight, to detect possible losses of unintentional or involuntary weight, and assess states of malnutrition. Onco-haematology had the highest recordings of patients’ weight as most chemotherapy treatments require dose adjustments depending on weight, in addition to the software used for prescription and validation of these treatments, which also requires that weight is indicated.
Conclusion The hospital has established a protocol for when a patient is admitted to hospital that nursing staff must collect weight and size when performing the physical examination. It is true that the patient’s circumstances may hinder assessment of weight, especially in elderly populations, but this is not usual. Many drugs are adjusted depending on weight, so that should affect the performance of a complete physical examination, allowing the clinician to undertake good prescription and validation.
References and/or acknowledgements Law 41/2002, 14 de noviembre (Spain).
Decreto 38/2012, 13 de marzo.
No conflict of interest
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