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.