Accuracy in documentation - a study of peripheral venous catheters.

AIM

The aim was to explore the extent of postinsertion documentation of peripheral venous catheters (PVCs) in patients' medical records, including the descriptions used to explain the PVC insertion site and determinants of PVC documentation.

BACKGROUND

Documentation in medical records is an important precondition for the safe handling of patients PVC. However, factors associated with documentation of PVCs and how the insertion site is described in medical records has not previously been studied.

DESIGN

This was a cross-sectional and descriptive study.

METHODS

A sample of 933 adult inpatients (women 45.7%) with PVC was recruited from medical and surgical wards at one university hospital and two general hospitals. A data collection form was used for registration of the insertion site of the PVC, hand side, lumen size, patient's age and gender. PVC documentation from medical records was transcribed. Factors associated with the documentation were analysed using logistic regression.

RESULTS

Ten descriptions used to explain the insertion site of the PVCs were identified in the patients' medical record. Any kind of PVC documentation was found in 71.8% and documentation that included insertion site, hand side and lumen size was recorded in 46.2% of the observed PVCs. Multivariate logistic regression revealed that PVC documentation was associated with medical wards at general hospitals (OR 4.59; 95% CI 3.10-6.81; p < 0.0001) and smaller lumen size (22 gauge) (OR 1.81; 95% CI 1.19-2.84, p = 0.006).

CONCLUSION

The extent of PVC documentation in medical records was low and descriptions used to explain the PVC insertion sites were found to vary appreciably. General hospitals and in particular medical wards and smaller lumen size, were associated with PVC documentation that included insertion site, hand side and lumen size.

RELEVANCE TO CLINICAL PRACTICE

Development of terms is needed to assure standardisation of postinsertion PVC documentation. Education of nurses on proper PVC documentation should be given priority.