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.

DESIGN

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

SETTING AND SUBJECTS

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.

INSTRUMENTS

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.