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Standard risk assessment forms help reduce preventable harm in older adult inpatients: A retrospective chart review
Chin-Yen Han1,2,3, Bernice Redley4, Chun-Chih Lin3,5
1Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.
Aims:
To examine nurse documentation of assessments using standard risk assessment forms in older inpatients, and to determine the value of such assessment.
Design:
Cross-sectional retrospective chart review.
Methods:
This retrospective review of risk evaluation documentation in patients' medical records focused on skin, continence, medical complications, nutrition, cognition, mobility, medications and pain.
Results:
A total of 1000 medical records from Taiwan hospitals were reviewed from January 2016 to December 2017, and 379 from Australian hospitals were reviewed from March 2011 to February 2012. Taiwanese patients with documented assessment of skin (aOR =2.94, 95%CI =1.88-4.54), nutrition (aOR =3.22, 95%CI =1.08-9.59), cognition (aOR =2.61, 95%CI =1.32-5.16) and pain (aOR =5.01, 95%CI=1.63-15.38) had significantly higher odds of developing new problems; while Australian patients with documented assessments of continence (aOR =11.55, 95%CI =1.48-90.45) and nutrition (aOR =12.90, 95%CI =1.67-99.06) had significantly higher odds of developing new problems.
Discussion:
Nursing assessments and interventions documented in standard risk assessment forms help clinical nurses detect new preventable problems and prevent harm in older hospital inpatients across geographic locations and hospital types. Standard nursing forms can be used in clinical practice to guide proactive care by nurses to prevent harm during hospitalisation.
Impact:
Older inpatients are at risk of preventable harm and new health problems. The present study found that incorporating eight factors sensitive to nursing care into standard risk assessment forms can help reduce preventable harm in older inpatients. In addition, these forms guide assessment and intervention effectively in different countries.
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