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dc.contributor.authorThoroddsen, Asta
dc.contributor.authorSigurjónsdóttir, Guðrún
dc.contributor.authorEhnfors, Margareta
dc.contributor.authorEhrenberg, Anna
dc.date.accessioned2014-05-23T09:12:41Z
dc.date.available2014-05-23T09:12:41Z
dc.date.issued2013-03
dc.date.submitted2014-05-23
dc.identifier.citationScand J Caring Sci 2013, 27(1):84-91en
dc.identifier.issn1471-6712
dc.identifier.pmid22630335
dc.identifier.doi10.1111/j.1471-6712.2012.01004.x
dc.identifier.urihttp://hdl.handle.net/2336/317343
dc.descriptionTo access publisher's full text version of this article. Please click on the hyperlink in Additional Links field.en
dc.description.abstractTo describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records.
dc.description.abstractA 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.
dc.description.abstractA 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.
dc.description.abstractThe 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.
dc.description.abstractThe 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.
dc.language.isoenen
dc.publisherWiley-Blackwellen
dc.relation.urlhttp://dx.doi.org/10.1111/j.1471-6712.2012.01004.xen
dc.relation.urlhttp://onlinelibrary.wiley.com/doi/10.1111/j.1471-6712.2012.01004.x/pdfen
dc.rightsArchived with thanks to Scandinavian journal of caring sciencesen
dc.subject.meshCross-Sectional Studiesen
dc.subject.meshHospitals, Universityen
dc.subject.meshHumansen
dc.subject.meshIcelanden
dc.subject.meshInformation Servicesen
dc.subject.meshMedical Recordsen
dc.subject.meshPilot Projectsen
dc.subject.meshPressure Ulceren
dc.titleAccuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record.en
dc.typeArticleen
dc.contributor.departmentUniv 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, Swedenen
dc.identifier.journalScandinavian journal of caring sciencesen
dc.rights.accessNational Consortium - Landsaðganguren
html.description.abstractTo describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records.
html.description.abstractA 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.
html.description.abstractA 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.
html.description.abstractThe 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.
html.description.abstractThe 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.


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