Abstract
The combination of nursing informatics knowledge with SQL code writing in an electronic health record is a powerful partnership to obtain meaningful information and improve healthcare. The purpose of this project is to use SQL and nursing informatics to identify the underpinnings and scope of present-on-patient-admission pressure ulcer documentation incongruence within the inpatient medical-surgical unit of a rural hospital. Project results reveal a 76% incidence rate of incongruent nurse and physician documentation of pressure ulcers as present on admission. However, the scope of such incongruence affects only 3% for the inpatient population. The high incidence rate of nurse-documented present-on-admission pressure ulcers without a physician diagnoses indicates a potential for lost rural hospital reimbursement and risk to patient care.
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