Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers

2.50
Hdl Handle:
http://hdl.handle.net/10755/151971
Type:
Presentation
Title:
Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers
Abstract:
Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers
Conference Sponsor:Sigma Theta Tau International
Conference Year:2011
Author:Padron Fajardo, Vivian, PhD, ARNP
P.I. Institution Name:University of Miami
Title:Assistant Professor
[22nd International Nursing Research Congress - Evidence-based Practice Presentation] Purpose: Nursing documentation has shifted from the written medical record to the Electronic health records (EHR) because use of the EHR is considered to be beneficial to the quality and safety of healthcare. After implementing EHR, improved tracking of pressure ulcers provides a comprehensive template to remind nurses to record the stage of pressure ulcers, size, location, risk assessment, nursing diagnosis, goals and planned interventions. The purpose of this pilot project was to track the EHR documentation of pressure ulcers on a medical surgical unit and compare the EHR record with the written medical record. Methods: A descriptive study design was completed to compare the EHR to the written medical record.  This pilot study was completed at a 560-bed hospital located in Miami, Florida. A convenience sample of 139 medical and surgical patients who met the inclusion criteria were used. Recorded data on pressure ulcers were retrospectively reviewed. Data collection included patient demographics, Braden Scale scores, presence of pressure ulcer, and detailed documentation of pressure ulcer on both EHR and written medical records. 
Results: A total of 11 patients (N=139) developed pressure ulcers. Inconsistencies were found in the nursing documentation of pressure ulcers when comparing the EHR to the written medical record. Conclusion: The results of this pilot study illustrated that the patient's records (both EHR and written) are not reflective of routine hospital policies for the documentation of pressure ulcers. Education related to the use of EHR for pressure ulcer documentation should be reinforced among nurses. In addition, there is a need for guidelines to standardize and routinely evaluate EHR documentation in clinical practice.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleDetermination of the Effectiveness of Electronic Health Records to Document Pressure Ulcersen_GB
dc.identifier.urihttp://hdl.handle.net/10755/151971-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2011</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Padron Fajardo, Vivian, PhD, ARNP</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">University of Miami</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Assistant Professor</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">vpfajardo@miami.edu</td></tr><tr><td colspan="2" class="item-abstract">[22nd International Nursing Research Congress - Evidence-based Practice Presentation] Purpose: Nursing documentation has shifted from the written medical record to the Electronic health records (EHR) because use of the EHR is considered to be beneficial to the quality and safety of healthcare. After implementing EHR, improved tracking of pressure ulcers provides a comprehensive template to remind nurses to record the stage of pressure ulcers, size, location, risk assessment, nursing diagnosis, goals and planned interventions. The purpose of this pilot project was to track the EHR documentation of pressure ulcers on a medical surgical unit and compare the EHR record with the written medical record. Methods: A descriptive study design was completed to compare the EHR to the written medical record. &nbsp;This pilot study was completed at a 560-bed hospital located in Miami, Florida. A convenience sample of 139 medical and surgical patients who met the inclusion criteria were used. Recorded data on pressure ulcers were retrospectively reviewed. Data collection included patient demographics, Braden Scale scores, presence of pressure ulcer, and detailed documentation of pressure ulcer on both EHR and written medical records.&nbsp; <br/>Results: A total of 11 patients (N=139) developed pressure ulcers. Inconsistencies were found in the nursing documentation of pressure ulcers when comparing the EHR to the written medical record.&nbsp;Conclusion: The results of this pilot study illustrated that the patient's records (both EHR and written) are not reflective of routine hospital policies for the documentation of pressure ulcers. Education related to the use of EHR for pressure ulcer documentation should be reinforced among nurses. In addition, there is a need for guidelines to standardize and routinely evaluate EHR documentation in clinical practice.</td></tr></table>en_GB
dc.date.available2011-10-26T11:19:47Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T11:19:47Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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