Monday, 11 April 2016

Doumenting pressure ulcers

Roger Watson, Editor

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.

Nursing homes were recruited through an email sent to nursing home managers in the municipalities connected to the Centre for Caring Research, southern Norway. Managers who wished to participate were invited to contact the project manager, one of the present authors (RLH), by phone or email. The inclusion criterion was all patients currently living in the nursing homes. Ethical considerations led to the exclusion of terminal patients and those considered by nursing staff to be too unwell. In total, 209
patients were invited to participate, and 155 (74%) patients or their proxies gave informed consent. Four of the five nursing homes had permanent-stay patients, including 2-4 patients in residential respite care or short-term stay.

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.


Hansen R-L, Fossum M (2016) Nursing documentation of pressure ulcers in nursing homes: comparison of record content and patient examinations Nursing Open doi: 10.1002/nop2.47

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