Documentation of pressure ulcers in medical records at an internal medicine ward in university hospital in western Sweden.
Julia Andersson, Sara Imberg, Kristina Rosengren
PMID 36303218WHAT IT FOUND
Pressure ulcer risk assessments and wound definitions were often missing or vague in the ward's medical records.
Key findings
01Risk assessments were documented in 68 of 1,458 care events.
02In care plans, 43 of 198 tissue damage entries were defined as pressure ulcers, while 147 lacked a clear definition or used other labels.
03In the point prevalence measurement, 3 of 14 patients had pressure ulcers, but 2 of those 3 lacked documentation in the medical records.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was done in one 24-bed ward at one Swedish university hospital, so the documentation patterns may not apply elsewhere. It reviewed records rather than examining patients directly, so missing or vague notes could look like low pressure ulcer prevalence. Data were care events, not unique patients, so the same person could be counted more than once. More than half of final notes lacked the mandatory pressure ulcer keyword (52.7%). The point prevalence sample was very small, with only 14 patients and 3 pressure ulcers. The authors state results were annual, so month-to-month or shift-level patterns were not shown.
Declared interests
The authors reported no financial support and no potential conflicts of interest.
The easy way to misread this
Do not conclude that pressure ulcers are rare in this ward. The low documented prevalence may reflect missing or vague records, and the one-day measurement found pressure ulcers in 3 of 14 patients.