Nursing documentation of pressure ulcers in nursing homes: comparison of record content and patient examinations

Abstract

Aim 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.

Design This study used a cross-sectional descriptive design.

Method A retrospective audit of 155 patients' records and patient examinations using the European Pressure Ulcer Advisory Panel form and the Braden scale, conducted in January and February 2013.

Results 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.