Document Detail

Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care.
MedLine Citation:
PMID:  18678726     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: To compare the accuracy in recording of pressure-ulcer prevalence and prevention before and after implementing an electronic health record (EHR) with templates for pressure-ulcer assessment. METHODS: All inpatients at the departments of surgery, medicine and geriatrics were inspected for the presence of pressure ulcers, according to the European Pressure Ulcer Advisory Panel-methodology, during 1 day in 2002 (n = 357) and repeated in 2006 (n = 343). The corresponding patient records were audited retrospectively for the presence of documentation on pressure ulcers. RESULTS: In 2002, the prevalence of pressure ulcers obtained by auditing paper-based patient records (n = 413) was 14.3%, compared with 33.3% in physical inspection (n = 357). The largest difference was seen in the geriatric department, where records revealed 22.9% pressure ulcers and skin inspection 59.3%. Four years later, after the implementation of the EHR, there were 20.7% recorded pressure ulcers and 30.0% found by physical examination of patients. The accuracy of the prevalence data had improved most in the geriatric department, where the EHR showed 48.1% and physical examination 43.2% pressure ulcers. Corresponding figures in the surgical department were 22.2% and 14.1%, and in the medical department 29.9% and 10.2%, respectively. The patients received pressure-reducing equipment to a higher degree (51.6%) than documented in the patient record (7.9%) in 2006. CONCLUSIONS: The accuracy in pressure-ulcer recording improved in the EHR compared with the paper-based health record. However, there were still deficiencies, which mean that patient records did not serve as a valid source of information on pressure-ulcer prevalence and prevention.
L Gunningberg; M Fogelberg Dahm; A Ehrenberg
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Publication Detail:
Type:  Comparative Study; Journal Article    
Journal Detail:
Title:  Quality & safety in health care     Volume:  17     ISSN:  1475-3901     ISO Abbreviation:  Qual Saf Health Care     Publication Date:  2008 Aug 
Date Detail:
Created Date:  2008-08-05     Completed Date:  2008-11-25     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101136980     Medline TA:  Qual Saf Health Care     Country:  England    
Other Details:
Languages:  eng     Pagination:  281-5     Citation Subset:  H    
Surgery Division, Uppsala University Hospital, Uppsala, Sweden.
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MeSH Terms
Data Collection / methods,  standards*
Hospitals, University
Medical Records Systems, Computerized*
Pressure Ulcer / epidemiology*,  prevention & control
Retrospective Studies

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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