Electronic versus paper records: documentation of pressure ulcer data

Area of Science:

• Healthcare Informatics
• Nursing Documentation
• Patient Data Management

Background:

• Accurate patient data documentation is crucial for effective healthcare.
• Electronic health records (EHRs) are increasingly adopted to enhance nursing documentation quality.
• This study focuses on the critical aspect of pressure ulcer data recording.

Purpose of the Study:

• To compare the accuracy and completeness of pressure ulcer documentation.
• To evaluate differences between electronic health records (EHRs) and traditional paper records.

Main Methods:

• A descriptive, comparative design utilizing retrospective patient record review.
• Two hospitals were selected: one using EHRs and one using paper records.
• Patient records were audited for pressure ulcer documentation accuracy and completeness.

Main Results:

• Electronic health records (EHRs) demonstrated higher documentation rates for pressure ulcers (83%) compared to paper records (71%).
• A higher percentage of patients with pressure ulcers had their condition documented in the EHR system.
• Despite improvements, both systems exhibited deficiencies in comprehensive pressure ulcer data recording.

Conclusions:

• Electronic health records (EHRs) offer superior accuracy and completeness in pressure ulcer documentation over paper records.
• Both EHRs and paper systems present challenges that need addressing for complete patient data.
• Enhancements in documentation practices are necessary for both electronic and paper-based health record systems.