Gunningberg Lena, Fogelberg-Dahm Marie, Ehrenberg Anna
Surgery Division, Uppsala University Hospital, Uppsala, Sweden.
J Clin Nurs. 2009 Jun;18(11):1557-64. doi: 10.1111/j.1365-2702.2008.02647.x. Epub 2009 Feb 12.
One aim was to compare the quality and comprehensiveness in nursing documentation of pressure ulcers before and after implementation of an electronic health record in a hospital setting. Another aim was to investigate the use of preformulated templates for pressure ulcer recording in the electronic health record.
With the possibilities of the electronic health record to provide information and give accurate and reliable feedback to the healthcare organisation, it is of high priority to develop standardised documentation practices for various areas of care (e.g. such as pressure ulcer care).
A cross-sectional retrospective review of health records.
Three departments in a Swedish university hospital participated. In 2002, there were 413 patients, including 59 paper-based records identified with notes on pressure ulcers and in 2006, 343 patients, including 71 electronic health records with pressure ulcer recording. Recorded data on pressure ulcers were retrospectively reviewed. Results. Significantly more patient records showed notes of pressure ulcer grade (p < 0.001), size (p = 0.004), risk assessment (p = 0.002), nursing history (p = 0.040), nursing diagnoses (p < 0.001), nursing goals (p < 0.001) and nursing outcomes (p = 0.016) in 2006 than in 2002. One third of the recordings used preformulated templates.
Although there were significant improvements in pressure ulcer recording after the change to the electronic health record, several deficiencies remained. Due to the short time of our follow-up after implementation of the electronic health record, we suspect that the quality of recording will improve when nurses become more familiar with the new system.
Education related to the use of the electronic health record and evidence-based pressure ulcer prevention should be provided to the nurses. To facilitate documentation, the templates need to be refined to be more user-friendly.
一个目的是比较在医院环境中实施电子健康记录前后压疮护理记录的质量和全面性。另一个目的是调查电子健康记录中预定义模板在压疮记录中的使用情况。
鉴于电子健康记录能够为医疗保健机构提供信息并给出准确可靠的反馈，为各个护理领域（如压疮护理）制定标准化的记录规范具有高度优先性。
对健康记录进行横断面回顾性研究。
瑞典一家大学医院的三个科室参与了研究。2002年有413名患者，其中59份纸质记录中有压疮相关记录；2006年有343名患者，其中71份电子健康记录中有压疮记录。对压疮记录数据进行回顾性分析。结果：与2002年相比，2006年显著更多的患者记录显示了压疮分级（p < 0.001）、大小（p = 0.004）、风险评估（p = 0.002）、护理史（p = 0.040）、护理诊断（p < 0.001）、护理目标（p < 0.001）和护理结果（p = 0.016）。三分之一的记录使用了预定义模板。
尽管改用电子健康记录后压疮记录有显著改善，但仍存在一些不足。由于在实施电子健康记录后我们的随访时间较短，我们怀疑当护士更熟悉新系统时记录质量将会提高。
应向护士提供与电子健康记录使用和循证压疮预防相关的教育。为便于记录，模板需要进一步完善以使其更便于用户使用。
