Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care

Abstract

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.