An audit of 155 patient records found large gaps between clinical practice and wound documentation in nursing homes.
In reviewing charts from five facilities, Norwegian and Australian researchers found they lacked key details about pressure ulcers and preventative interventions, even when patient exams showed measures like pressure-relieving mattresses were in use.
The researchers theorize inaccuracies were linked to nurses who “do not have time, skills and knowledge to update patient records.”
They suggest more training for high-quality care and documentation, as well as adopting electronic health records with decision-support tools.
The researchers estimate incomplete reporting in 30% to 62% of pressure wound cases. In 45% of their cases, pressure ulcers were not graded.
“Our study highlights a gap between the use of preventative strategies documented in patient records and data from patient examinations,” wrote lead investigator Ruth-Linda Hansen of the health and sport sciences faculty at University of Agder.
That lack of accuracy could challenge the use of patient records as a valid support for specific patient care strategies.