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

Sep 29, 2026

Uploaded by Jasmine

Cross-sectional research in a rehabilitation hospital assessed 136 antimicrobial prescriptions after recent electronic medication order entry, with no mandatory EHR documentation requirements. Findings showed incomplete recording of antimicrobial indication (37%) and duration (75%). A related prescriber survey highlighted improvement approaches, including reminders, refined choice architecture, and forced-function design to support accurate stewardship documentation. The study examines practice gaps relevant to safer antibiotic prescribing.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

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Abstract

Introduction

Methods

Study design and setting

Participants

Outcomes and data sources

Antimicrobial Stewardship & Healthcare Epidemiology (2026), 6, e4, 1–3 doi:10.1017/ash.2025.10259 Concise Communication Documentation of antimicrobial indication and duration in electronic health records in a rehabilitation hospital: a cross-sectional study Lilah Moccia BHSc 1, Cassidy Arvinte BA, MD2 , Jennifer Lee MN3 and Bradley J. Langford PharmD4,5 1Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada, 2American University of the Caribbean School of Medicine, Cupecoy, St. Maarten, 3Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada, 4Hotel Dieu Shaver Health and Rehabilitation Centre, McMaster University, Hamilton, ON, Canada and 5Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada Abstract In this cross-sectional study of136 antimicrobial prescriptionsat a rehabilitation hospital with recent implementation ofelectronic 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. (Received 24 September 2025; accepted 3 December 2025) Introduction Appropriate antimicrobial prescribing can be facilitated through electronic medical records. Clinical decision support encompasses a range of supports to optimize antibiotic prescribing, including order sets for antibiotic selection, dose, and duration, positive culture alerts, and risk stratification for antimicrobial resistance. However, foundational to such efforts is appropriate documentation and order attributes when prescribing antimicrobials. Indication and duration documentation on antimicrobial prescriptions are two such examples. Including an indication on an antimicrobial prescription is recommended to help facilitate selection of appropriate antimicrobial regimens, communication between the interprofessional team, and antimicrobial stewardship audits.1,2 Despite these purported benefits, antimicrobial indication is often not included as part of the prescription.3,4 Similarly, a lack of inclusion of duration on antimicrobial prescriptions risks unnecessarily prolonged duration and preventable harm for patients. However, there are limited data on how often duration is missing from prescriptions, and the potential impact of such omissions. A better understanding of the current documentation practice and barriers and facilitators to optimal practice is needed, particularly in less studied settings like rehabilitation hospitals. This will help inform strategies to improve antibiotic stewardship and promote safer, more effective prescribing for our patients. Our objective was to evaluate the prevalence of antimicrobial indication and duration documentation and describe the determinants to improve documentation. Corresponding author: Bradley J. Langford; Email: [brad.langford@gmail.com](brad.langford@gmail.com) [Cite this article:](Cite this article: Moccia L)[ Moccia L](Cite this article: Moccia L), [Arvinte C](Arvinte C), [Lee J](Lee J), [Langford BJ](Langford BJ). Documentation of antimicrobial indication and duration in electronic health records in a rehabilitation hospital: across-sectional study. Antimicrob Steward HealthcEpidemiol 2026. doi: 10.1017/ ash.2025.10259 Methods Study design Cross-sectional study which includes both a retrospective chart review of antimicrobial prescriptions, and a survey of prescribers. Setting Hotel Dieu Shaver Health and Rehabilitation Centre is a complex continuing care and rehabilitation facility in Ontario, Canada. As a community-based rehabilitation center, it services 137 beds broken into 37 acute rehabilitation beds allocating 2–3 hours a day to rehabilitation, 85 low intensity rehabilitation beds allocating 1–2 hours a day, 10 medical complex beds receiving medical services only and 5 palliative beds. A

FAQs

What documentation elements were evaluated for antimicrobial prescriptions?

The study assessed whether prescriptions included a documented antimicrobial indication and whether a documented duration was included in the order.

What were the main documentation gaps found in the rehabilitation hospital?

Indication documentation was incomplete (37%), while duration documentation was also frequently missing (75%).

What solutions did the accompanying survey suggest to improve documentation?

Potential solutions included reminders, improved choice architecture, and forced functions to better support correct indication and duration entry in the EHR.

Sep 29, 2026

Uploaded by Jasmine