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:Toevaluatethecompletionofnursingrecordsthroughscheduledauditstoanalyseriskoutcomeindicators. Background:Nursingrecordssupportclinicaldecision-makingandencouragecontinuityofcare,hencetheimportanceofauditingtheircompletioninordertotakecorrectiveactionwherenecessary. Method:Thiswasanobservationaldescriptivestudycarriedout fromFebruaryto November 2020with a sample of 1131 electronic health records belonging to patientsadmittedtoCOVID-19hospitalunitsduringthreeobservationperiods:prepandemic,firstwave,andsecondwave. Results: Asignificant reduction innursing recordcompletion rateswasobserved betweenpre-pandemicperiodand first andsecondwaves: Bradenscale40.97%, 28.02%, and30.99%;Downtonscale: 43.74%, 22.34%, and33.91%;Gijonscale: 40.12%, 26.23%, and33.64%(p<0.001).Therewasanincrease inthenumberof records completedbetween the first and secondwaves following themeasures adoptedafterthequalityaudit. Conclusions: Theuseof scheduledauditsofnursing recordsasquality indicators facilitatedthedetectionofareasforimprovement,allowingtimelycorrectiveactions. Implications forNursingManagement: Support fromnursingmanagers at health carefacilitiestoimplementqualityassessmentprogrammesencompassingauditsof clinical recordcompletionwill encourage theadoptionofmeasures for corrective action.