Electronic versus paper records: documentation of pressure ulcer data.

ABSTRACT

BACKGROUND: The documentation of patient data on health records is a vital component of the care process. Accurate and complete recording of this data is a necessary practice. The adoption of electronic health records to improve the quality of nursing documentation is on the rise. OBJECTIVES: This study compares the accuracy and completeness of pressure ulcer data documentation between electronic and paper records. DESIGN: A descriptive, comparative design with a retrospective review of patient records. Settings and sample Two hospitals were chosen purposefully, one using electronic recording of patient data and the other using paper records. METHODS: In the first phase, all hospitalised patients aged 18 years and over were inspected for pressure ulcers. In the second phase, the files of patients with pressure ulcers were audited. RESULTS: Of the 52 patients with ulcers found in the hospital that used an electronic system, 43 of their records documented the pressure ulcers (83%). Of the 55 patients with pressure ulcers in the hospital using paper records, 39 files had corresponding documentation of the presence of a pressure ulcer (71%). CONCLUSION: In terms of accuracy and completeness, more comprehensive documentation practice was found on the electronic health records compared with paper records. However, both types of systems have shortcomings in the practice of pressure ulcer data documentation.