Aims: One aim was to compare the quality and comprehensiveness in nursing documentation of pressure ulcers before and after implementation of an electronic health record in a hospital setting. Another aim was to investigate the use of preformulated templates for pressure ulcer recording in the electronic health record.
Background: With the possibilities of the electronic health record to provide information and give accurate and reliable feedback to the healthcare organisation, it is of high priority to develop standardised documentation practices for various areas of care (e.g. such as pressure ulcer care).
Design: A cross-sectional retrospective review of health records.
Methods: Three departments in a Swedish university hospital participated. In 2002, there were 413 patients, including 59 paper-based records identified with notes on pressure ulcers and in 2006, 343 patients, including 71 electronic health records with pressure ulcer recording. Recorded data on pressure ulcers were retrospectively reviewed. Results. Significantly more patient records showed notes of pressure ulcer grade (p < 0.001), size (p = 0.004), risk assessment (p = 0.002), nursing history (p = 0.040), nursing diagnoses (p < 0.001), nursing goals (p < 0.001) and nursing outcomes (p = 0.016) in 2006 than in 2002. One third of the recordings used preformulated templates.
Conclusions: Although there were significant improvements in pressure ulcer recording after the change to the electronic health record, several deficiencies remained. Due to the short time of our follow-up after implementation of the electronic health record, we suspect that the quality of recording will improve when nurses become more familiar with the new system.
Relevance to clinical practice: Education related to the use of the electronic health record and evidence-based pressure ulcer prevention should be provided to the nurses. To facilitate documentation, the templates need to be refined to be more user-friendly.