Nursing documentation of pressure ulcers in nursing homes: comparison of record content and patient examinations

被引：13
作者：
Hansen, Ruth-Linda [1 ]
Fossum, Mariann [1 ,2 ]
机构：
[1] Univ Agder, Ctr Caring Res, Fac Hlth & Sport Sci, Dept Hlth & Nursing Sci, Grimstad Southern Norway, Norway
[2] Deakin Univ, Alfred Hlth, Deakin Alfred Hlth Nursing Res Ctr, Sch Nursing & Midwifery, Melbourne, Vic, Australia
来源：
NURSING OPEN | 2016年 / 3卷 / 03期
关键词：
Electronic health records; nursing home; patient examination; pressure ulcer;
D O I：
10.1002/nop2.47
中图分类号：
R47 [护理学];
学科分类号：
1011 ;
摘要：
Aim The aim of this study was to describe the accuracy and quality of nursing documentation of the prevalence, risk factors and prevention of pressure ulcers, and compare retrospective audits of nursing documentation with patient examinations conducted in nursing homes. Design This study used a cross-sectional descriptive design. Method A retrospective audit of 155 patients' records and patient examinations using the European Pressure Ulcer Advisory Panel form and the Braden scale, conducted in January and February 2013. Results The prevalence of pressure ulcers was 38 (26%) in the audit of the patient records and 33 (22%) in patient examinations. A total of 17 (45%) of the documented pressure ulcers were not graded. When comparing the patient examinations with the patient record contents, the patient records lacked information about pressure ulcers and preventive interventions.
引用
收藏
页码：159 / 167
页数：9
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