Documentation of antimicrobial indication and duration in electronic health records in a rehabilitation hospital: a cross-sectional study

2025/12/19 by Lilah Moccia, Cassidy Arvinte, Jennifer Lee +1 · 2 voices · 1 citation
Health Professions · Immunology and Microbiology · Pharmacology, Toxicology and Pharmaceutics · #Electronic Health Records Systems #Antibiotic Use and Resistance #Pharmacovigilance and Adverse Drug Reactions

paper · pdf · doi:10.1017/ash.2025.10259

openalex publication_date 2025/12/19 · openalex created_date 2025/12/19 · openalex updated_date 2026/07/23

Abstract

In this cross-sectional study of 136 antimicrobial prescriptions at a rehabilitation hospital with recent implementation of electronic medication order entry and no mandatory requirements, we found incomplete documentation of both indication (37%) and duration (75%). An accompanying survey identified potential solutions including reminders, improved choice architecture, and forced functions.

Cited by

• Clinical decision-making and documentation gaps associated with influenza antiviral treatment in hospitalized children

Discussions

• How can the EHR improve Antimicrobial Stewardship? 🏥💊 Our study of 136 prescriptions found only 37% included an indication and 75% a duration. ASPs should consider: ✅ Required indication/duration ✅ [bsky, 3 points, 0 comments]
• @brxad.bsky.social et al: Electronic health record documentation is incomplete for antimicrobial indication (37%) and duration (75%) when there is no mandatory requirement for these fields. Potential [bsky, 2 points, 0 comments]

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