Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care.
OBJECTIVE
To compare the accuracy in recording of pressure-ulcer prevalence and prevention before and after implementing an electronic health record (EHR) with templates for pressure-ulcer assessment.


METHODS
All inpatients at the departments of surgery, medicine and geriatrics were inspected for the presence of pressure ulcers, according to the European Pressure Ulcer Advisory Panel-methodology, during 1 day in 2002 (n = 357) and repeated in 2006 (n = 343). The corresponding patient records were audited retrospectively for the presence of documentation on pressure ulcers.


RESULTS
In 2002, the prevalence of pressure ulcers obtained by auditing paper-based patient records (n = 413) was 14.3%, compared with 33.3% in physical inspection (n = 357). The largest difference was seen in the geriatric department, where records revealed 22.9% pressure ulcers and skin inspection 59.3%. Four years later, after the implementation of the EHR, there were 20.7% recorded pressure ulcers and 30.0% found by physical examination of patients. The accuracy of the prevalence data had improved most in the geriatric department, where the EHR showed 48.1% and physical examination 43.2% pressure ulcers. Corresponding figures in the surgical department were 22.2% and 14.1%, and in the medical department 29.9% and 10.2%, respectively. The patients received pressure-reducing equipment to a higher degree (51.6%) than documented in the patient record (7.9%) in 2006.


CONCLUSIONS
The accuracy in pressure-ulcer recording improved in the EHR compared with the paper-based health record. However, there were still deficiencies, which mean that patient records did not serve as a valid source of information on pressure-ulcer prevalence and prevention.
Gunningberg
L
L
Surgery Division, Uppsala University Hospital, Uppsala, Sweden. lena.gunningberg@akademiska.se
Dahm
M Fogelberg
MF
Ehrenberg
A
A
D003625:Data Collection / Q000379:methods / Q000592:standards*; D006785:Hospitals, University; D006801:Humans; D016347:Medical Records Systems, Computerized; D003668:Pressure Ulcer / Q000453:epidemiology* / Q000517:prevention & control; D015995:Prevalence; D012189:Retrospective Studies; D013548:Sweden