Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record.
To access publisher's full text version of this article. Please click on the hyperlink in Additional Links field. To describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records. A cross-sectional descriptive study performed in 29 war...
Published in: | Scandinavian Journal of Caring Sciences |
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Online Access: | http://hdl.handle.net/2336/317343 https://doi.org/10.1111/j.1471-6712.2012.01004.x |
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ftlandspitaliuni:oai:www.hirsla.lsh.is:2336/317343 2023-05-15T16:48:44+02:00 Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. Thoroddsen, Asta Sigurjónsdóttir, Guðrún Ehnfors, Margareta Ehrenberg, Anna Univ Orebro, Sch Hlth & Med Sci, Orebro, Sweden Univ Iceland, IS-101 Reykjavik, Iceland Landspitali Univ Hosp, Reykjavik, Iceland Dalarna Univ, Sch Hlth & Social Studies, Falun, Sweden 2014-05-23 http://hdl.handle.net/2336/317343 https://doi.org/10.1111/j.1471-6712.2012.01004.x en eng Wiley-Blackwell http://dx.doi.org/10.1111/j.1471-6712.2012.01004.x http://onlinelibrary.wiley.com/doi/10.1111/j.1471-6712.2012.01004.x/pdf Scand J Caring Sci 2013, 27(1):84-91 1471-6712 22630335 doi:10.1111/j.1471-6712.2012.01004.x http://hdl.handle.net/2336/317343 Scandinavian journal of caring sciences Archived with thanks to Scandinavian journal of caring sciences National Consortium - Landsaðgangur Cross-Sectional Studies Hospitals University Humans Iceland Information Services Medical Records Pilot Projects Pressure Ulcer Article 2014 ftlandspitaliuni https://doi.org/10.1111/j.1471-6712.2012.01004.x 2022-05-29T08:21:56Z To access publisher's full text version of this article. Please click on the hyperlink in Additional Links field. To describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records. A cross-sectional descriptive study performed in 29 wards at a university hospital in Iceland. The study included skin assessment of patients and retrospective audits of records of patients identified with pressure ulcers. A sample of 219 patients was inspected for signs of pressure ulcers on 1 day in 2008. Records of patients identified with pressure ulcers were audited (n = 45) retrospectively. The prevalence of pressure ulcers was 21%. Information in patient records lacked accuracy, completeness and comprehensiveness. Only 60% of the identified pressure ulcers were documented in the patient records. The lack of accuracy was most prevalent for stage I pressure ulcers. The purpose of documentation to record, communicate and support the flow of information in the patient record was not met. The patient records lacked accuracy, completeness and comprehensiveness, which can jeopardise patient safety, continuity and quality of care. The information on pressure ulcers in patient records was found not to be a reliable source for the evaluation of quality in health care. To improve accuracy, completeness and comprehensiveness of data in the patient record, a systematic risk assessment for pressure ulcers and assessment and treatment of existing pressure ulcers based on evidence-based guidelines need to be implemented and recorded in clinical practice. Health information technology, including the electronic health record with decision support, has shown promising results to facilitate and improve documentation of pressure ulcers. Article in Journal/Newspaper Iceland Hirsla - Landspítali University Hospital research archive Scandinavian Journal of Caring Sciences 27 1 84 91 |
institution |
Open Polar |
collection |
Hirsla - Landspítali University Hospital research archive |
op_collection_id |
ftlandspitaliuni |
language |
English |
topic |
Cross-Sectional Studies Hospitals University Humans Iceland Information Services Medical Records Pilot Projects Pressure Ulcer |
spellingShingle |
Cross-Sectional Studies Hospitals University Humans Iceland Information Services Medical Records Pilot Projects Pressure Ulcer Thoroddsen, Asta Sigurjónsdóttir, Guðrún Ehnfors, Margareta Ehrenberg, Anna Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
topic_facet |
Cross-Sectional Studies Hospitals University Humans Iceland Information Services Medical Records Pilot Projects Pressure Ulcer |
description |
To access publisher's full text version of this article. Please click on the hyperlink in Additional Links field. To describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records. A cross-sectional descriptive study performed in 29 wards at a university hospital in Iceland. The study included skin assessment of patients and retrospective audits of records of patients identified with pressure ulcers. A sample of 219 patients was inspected for signs of pressure ulcers on 1 day in 2008. Records of patients identified with pressure ulcers were audited (n = 45) retrospectively. The prevalence of pressure ulcers was 21%. Information in patient records lacked accuracy, completeness and comprehensiveness. Only 60% of the identified pressure ulcers were documented in the patient records. The lack of accuracy was most prevalent for stage I pressure ulcers. The purpose of documentation to record, communicate and support the flow of information in the patient record was not met. The patient records lacked accuracy, completeness and comprehensiveness, which can jeopardise patient safety, continuity and quality of care. The information on pressure ulcers in patient records was found not to be a reliable source for the evaluation of quality in health care. To improve accuracy, completeness and comprehensiveness of data in the patient record, a systematic risk assessment for pressure ulcers and assessment and treatment of existing pressure ulcers based on evidence-based guidelines need to be implemented and recorded in clinical practice. Health information technology, including the electronic health record with decision support, has shown promising results to facilitate and improve documentation of pressure ulcers. |
author2 |
Univ Orebro, Sch Hlth & Med Sci, Orebro, Sweden Univ Iceland, IS-101 Reykjavik, Iceland Landspitali Univ Hosp, Reykjavik, Iceland Dalarna Univ, Sch Hlth & Social Studies, Falun, Sweden |
format |
Article in Journal/Newspaper |
author |
Thoroddsen, Asta Sigurjónsdóttir, Guðrún Ehnfors, Margareta Ehrenberg, Anna |
author_facet |
Thoroddsen, Asta Sigurjónsdóttir, Guðrún Ehnfors, Margareta Ehrenberg, Anna |
author_sort |
Thoroddsen, Asta |
title |
Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
title_short |
Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
title_full |
Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
title_fullStr |
Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
title_full_unstemmed |
Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
title_sort |
accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. |
publisher |
Wiley-Blackwell |
publishDate |
2014 |
url |
http://hdl.handle.net/2336/317343 https://doi.org/10.1111/j.1471-6712.2012.01004.x |
genre |
Iceland |
genre_facet |
Iceland |
op_relation |
http://dx.doi.org/10.1111/j.1471-6712.2012.01004.x http://onlinelibrary.wiley.com/doi/10.1111/j.1471-6712.2012.01004.x/pdf Scand J Caring Sci 2013, 27(1):84-91 1471-6712 22630335 doi:10.1111/j.1471-6712.2012.01004.x http://hdl.handle.net/2336/317343 Scandinavian journal of caring sciences |
op_rights |
Archived with thanks to Scandinavian journal of caring sciences National Consortium - Landsaðgangur |
op_doi |
https://doi.org/10.1111/j.1471-6712.2012.01004.x |
container_title |
Scandinavian Journal of Caring Sciences |
container_volume |
27 |
container_issue |
1 |
container_start_page |
84 |
op_container_end_page |
91 |
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1766038829152600064 |