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.

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    • 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. [ABSTRACT FROM AUTHOR]
    • Abstract:
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