Construction and application of an ICU nursing electronic medical record quality control system in a Chinese tertiary hospital: a prospective controlled trial

ICU nurses provide critical care and meticulously document electronic medical records (EMRs), tracking vital signs, interventions, and medication hourly. Despite China’s ICUs effectively integrating real-time monitor and ventilator data into EMRs, challenges persist. Patient movements can introduce inaccuracies, and the demands of critical care may lead nurses to miss assessments like pain and nutrition. Traditional manual EMR verification is inefficient and error-prone, highlighting the urgent need for standardized, technology-aided EMR practices in ICU nursing. This study aimed to describe the development and evaluation of an electronic medical records quality control system implemented in a Chinese tertiary care ICU setting, where current practices impact the accuracy of electronic medical records. A prospective controlled trial was conducted with 600 ICU patients in Zhejiang Province from January to December 2023. An automated EMR quality control system was implemented in July 2023, facilitating real-time data collection and quality control for vital signs, medication management, and nursing evaluations. After implementing the ICU nursing electronic medical record quality control system, the prevalence of false data on vital signs decreased from 9 to 1.33