Information Gaps in the Care Pathway of Neurosurgical Patients: A Prerequisite Study for Electronic Health Record Design
| Author | Mina Lazem | en |
| Author | Sajjad Aliazdeh | en |
| Orcid | Mina Lazem [0000-0002-2891-4571] | en |
| Orcid | Sajjad Aliazdeh [0000-0002-2337-0309] | en |
| Issued Date | 2026-06-30 | en |
| 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. | en |
| DOI | https://doi.org/10.5812/jcrps-172504 | en |
| URI | https://brieflands.com/journals/jcrps/articles/172504 | en |
| Keyword | Information Gaps | en |
| Keyword | Electronic Health Record | en |
| Keyword | Neurosurgery | en |
| Keyword | Documentation | en |
| Keyword | Care Pathway | en |
| Publisher | Brieflands | en |
| Title | Information Gaps in the Care Pathway of Neurosurgical Patients: A Prerequisite Study for Electronic Health Record Design | en |
| Type | Research Article | en |
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