Auditing completion of nursing records as an outcome indicator for identifying patients at risk of developing pressure ulcers, falling, and social vulnerability: An observational study

Abstract

Aim: To evaluate the completion of nursing records through scheduled audits to analyse risk outcome indicators.

Background: Nursing records support clinical decision-making and encourage continuity of care, hence the importance of auditing their completion in order to take corrective action where necessary.

Method: This was an observational descriptive study carried out from February to November 2020 with a sample of 1131 electronic health records belonging to patients admitted to COVID-19 hospital units during three observation periods: pre-pandemic, first wave, and second wave.

Results: A significant reduction in nursing record completion rates was observed between pre-pandemic period and first and second waves: Braden scale 40.97%, 28.02%, and 30.99%; Downton scale: 43.74%, 22.34%, and 33.91%; Gijón scale: 40.12%, 26.23%, and 33.64% (p < 0.001). There was an increase in the number of records completed between the first and second waves following the measures adopted after the quality audit.

Conclusions: The use of scheduled audits of nursing records as quality indicators facilitated the detection of areas for improvement, allowing timely corrective actions.

Implications for nursing management: Support from nursing managers at health care facilities to implement quality assessment programmes encompassing audits of clinical record completion will encourage the adoption of measures for corrective action.

Keywords: documentation; evaluation; hospital organisation; indicators.