Accuracy and quality in the nursing documentation of pressure ulcers: a comparison of record content and patient examination.
OBJECTIVE
To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting.


METHODS
A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients.


METHODS
All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital.


METHODS
The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation.


METHODS
All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments.


RESULTS
The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor.


CONCLUSIONS
Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.
Gunningberg
Lena
L
Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden. lena.gunningberg@akademiska.se
Ehrenberg
Anna
A
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D004282:Documentation / Q000592:standards*; D005260:Female; D006301:Health Services Needs and Demand; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment / Q000592:standards*; D009731:Nursing Audit; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000592:standards*; D015588:Observer Variation; D010808:Physical Examination / Q000451:nursing / Q000592:standards*; D017410:Practice Guidelines as Topic; D003668:Pressure Ulcer / Q000175:diagnosis / Q000453:epidemiology / Q000451:nursing*; D015995:Prevalence; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013548:Sweden / Q000453:epidemiology