Improving Braden Scale Risk Assessment Documentation: A Two-Cycle Clinical Audit at Al-Managil Teaching Hospital,...

Area of Science:

• Healthcare Quality Improvement
• Clinical Documentation
• Pressure Injury Prevention

Background:

• Accurate Braden Scale documentation is crucial for identifying patients at risk of pressure injuries.
• Poor compliance with Braden Scale assessment and documentation was observed at Al-Managil Teaching Hospital, Sudan.

Purpose of the Study:

• To evaluate the impact of an educational and documentation-standardization intervention on Braden Scale documentation completeness.
• To assess improvements in pressure injury risk identification through enhanced documentation.

Main Methods:

• A closed-loop clinical audit involving two cycles of 51 patient records each.
• Intervention included staff education and a standardized Braden Scale documentation form over two months.
• Data analysis utilized descriptive statistics and chi-square testing to determine documentation improvement.

Main Results:

• Baseline Braden Scale documentation was 0% complete for all components.
• Post-intervention (Cycle 2), 100% completion was achieved for all Braden Scale components.
• Significant improvements were noted in patient identifiers, administrative fields, subscale documentation, risk scoring, and action notes (p < 0.001).

Conclusions:

• Targeted education and a standardized tool significantly improved Braden Scale documentation quality.
• These cost-effective interventions can bolster pressure injury prevention in resource-limited environments.
• Continued monitoring and re-auditing are recommended for sustained compliance and clinical impact assessment.