Information Gaps in the Care Pathway of Neurosurgical Patients: A Prerequisite Study for Electronic Health Record Design

Abstract

Background: Continuity of neurosurgical care depends on comprehensive documentation. This study identifies information gaps to guide electronic health record (EHR) design. Objectives: To assess the completeness of documentation across the entire neurosurgical care pathway, from admission to discharge, and identify gaps to inform EHR design. Methods: A retrospective review of 621 neurosurgical records was conducted using a 31-item checklist designed to assess documentation completeness across the entire care pathway. Results: Among the 621 records, the mean age was 51.8 ± 19.3 years, and 54.3% of patients were male. Demographic data were highly complete, with age documented in 98.2% and gender in 99.8% of records. However, substantial documentation deficits were identified: intraoperative complications were documented in only 15.8% of records, pupil examinations on intensive care unit (ICU) admission in 34.8%, active medication lists during ICU-to-ward transfer in 19.8%, and final pathology reports at discharge in only 23.8%. Conclusions: Significant but modifiable information gaps exist in current documentation systems, particularly during care transitions. These findings provide an evidence-based roadmap for phased, problem-oriented EHR implementation. Although the specific frequencies of these gaps may vary across settings, the pattern of transition-related gaps is likely applicable to other resource-limited neurosurgical centers.