Abstract
AimThe aim of this study was to describe the accuracy and quality of nursing documentation of the prevalence, risk factors and prevention of pressure ulcers, and compare retrospective audits of nursing documentation with patient examinations conducted in nursing homes.DesignThis study used a cross‐sectional descriptive design.MethodA retrospective audit of 155 patients' records and patient examinations using the European Pressure Ulcer Advisory Panel form and the Braden scale, conducted in January and February 2013.ResultsThe prevalence of pressure ulcers was 38 (26%) in the audit of the patient records and 33 (22%) in patient examinations. A total of 17 (45%) of the documented pressure ulcers were not graded. When comparing the patient examinations with the patient record contents, the patient records lacked information about pressure ulcers and preventive interventions.
Highlights
Pressure ulcers (PUs) remain a serious health problem for older adult patients in nursing homes (Kwong et al 2009, Demarre et al 2012, Baath et al 2014), despite a widespread focus on the prevention of PUs (Fossum et al 2011, Beeckman et al 2013, Baath et al 2014)
This study aimed to describe the accuracy and quality of nursing documentation of PU prevalence, risk factors and prevention and compare retrospective audits of nursing documentation with patient examinations conducted in nursing homes
The comparisons between the 155 patient examinations and the content of the nursing documentation showed that the prevalence of PUs was 33 (21%, 95% confidence interval (95% CI), 21-29%) according to the patient examinations
Summary
Pressure ulcers (PUs) remain a serious health problem for older adult patients in nursing homes (Kwong et al 2009, Demarre et al 2012, Baath et al 2014), despite a widespread focus on the prevention of PUs (Fossum et al 2011, Beeckman et al 2013, Baath et al 2014). Improving risk assessment, planning and documentation is important to help prevent PUs in nursing homes (Moore & Cowman 2012). To avoid the consequences of PUs, it is important to gain knowledge about the accuracy of nursing documentation related to PUs and how nurses in nursing homes communicate PU prevention strategies. An audit of record accuracy may provide important information about the documentation of prevalence, risk factors and prevention of PUs. In addition, patient examinations can provide information about the accuracy of the nursing documentation, and what nurses are doing and observing for their patients. A recent review found no evidence that implementing standardized PU risk assessment scales had an impact on clinical practice, there was rationale for using these scales as quality indicators for the care process (Kottner & Balzer 2010)
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