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Determination of the EffectivenessOf Electronic Health RecordsTo Document Pressure Ulcers

Dan LiDenise M. Korniewicz

A doption of the electronichealth record (EHR) hasincreased in the United

States to approximately 17% andcontinues to rise steadily (Poon etal., 2010). Nursing documentationhas shifted from the written med-ical record to the EHR because itsuse is beneficial to health care qual-ity and safety. Basic EHR systemshave been defined by the Instituteof Medicine (2003) as:

(1) A longitudinal collection ofelectronic health informationabout a person, or healthcareprovided; (2) immediate elec-tronic access to a person or pop-ulation level information byauthorized users; (3) provisionof knowledge and decision-sup-port that enhance the quality,safety, and efficiency of patientcare; and (4) support of efficientprocesses for healthcare delivery.

(P.l)Throughout health care facilities,

various forms of EHR systems havedifferent functions. Most EHRs rep-resent medical concepts that formthe content area and are based onprofessional nursing organizationstandards, regulatory requirements,and other evidence-based practice(EBP) sources. EHRs rooted in EBPhave eight core functions: decisionsupport, health information anddata, results management, orderentry, electronic communicationand connectivity, patient support,administrative processes, and popu-lation health management (Jamal,McKenzie, & Clark, 2009). An EHRrefers to an information repository

The purpose of this pilot project was to track the electronic healthrecord documentation of pressure ulcers on a medical-surgical unitand compare the electronic health record with the written medicalrecord.

in which patient data are stored indigital form. It contains retrospec-tive, concurrent, and prospectiveinformation, and its primary pur-pose is to support continuing, effi-cient, integrated quality health care.The combination of structured dataand the development of a robustnational vocabulary delivers a con-sistent representation of whatproviders do during the delivery ofhealth care. Standardized documen-tation allows the use of data fromEHRs to learn about health care, pre-ventive actions, and outcomes ofnursing interventions. Moreover,EHRs can facilitate communicationbetween health care professionals(HCPs), promote safety, reduce costs,and facilitate EBP (Poon et al., 2010;Wrenn, Stein, Bakken, & Stetson,2010).

The template in the EHR canallow physicians and other HCPs tosee the information they most need.Also, documentation takes less time.Description about patient assess-ment results is one advantage of theEHR. Another advantage is improvedcommunication among HCPs be-

cause data are readily available andcan improve patient care quality.The EHR allows physicians to haveaccess to patient health informationand data to facilitate timely clinicaldecisions. The records can be viewedby physicians when and where theyare needed, which allows for the pre-vention and treatment of pressureulcers. Other benefits include avail-ability of data for health serviceresearchers and public health offi-cials. In order to coordinate withpublic health monitoring, qualitymonitoring, and research, the EHRprovides easier access to collect infor-mation (Holroyd-Eeduc, Lorenzetti,Straus, Sykes, & Ouan, 2011).

Nurses play an important role inthe adoption, assessment, and use ofEHRs. Törnvall, Wilhelmsson, andWahren (2004) found nursesresponded positively to the struc-tured form of the EHR because docu-mentation was facilitated, clinicaldecisions were documented, andpatient care was assessed. Mahlerand colleagues (2007) demonstratedthe quality of nursing documenta-tion improved after introduction of a

Dan Li, BSN, RN, is Doctoral Student, University of Miami, School of Nursing & Health Studies,Coral Gables, FL.

Denise M. Korniewicz, PhD, RN, FAAN, is Dean and Professor, University of North DakotaCollege of Nursing, Grand Forks, ND.

MEDSURG lanuary-February 2013 • Vol. 22/No. 1 17

CNEIntroduction

Nursing documentation has shifted from the written medical record to the elec-tronic health record (EHR) because use of the EHR is considered to be beneficialto the quality and safety of health care. After implementation of the EHR,improved communication between certified nursing assistants, dietary staff,social workers, and nurses should result in more timely referrals, treatments, andchanges in care plans. The EHR provides a comprehensive template to remindnurses to record the pressure ulcer stage, size, location, risk assessment, nursingdiagnoses, goals, and planned interventions.

Purpose

The purpose of this pilot project was to track the EHR documentation of pres-sure ulcers on a medical-surgical unit and compare the EHR with the writtenmedical record.

Method

A pilot study was completed at a 560-bed hospital located in Miami, FL. A con-venience sample of 139 medical and surgical patients who met the inclusion cri-teria was used. Recorded data on pressure ulcers were reviewed retrospectively.Data collection included patient demographics, Braden Scale scores, presence ofpressure ulcer, and detailed documentation of pressure ulcer on both the EHRand written medical record. A descriptive study design was completed to com-pare the EHR to the written medical record.

Findings

Eleven patients (N=l 39) developed pressure ulcers. Inconsistencies were found inthe nursing documentation of pressure ulcers when comparing the EHR to thewritten medical record.

Conclusions

Results of this pilot study illustrated that patients' records (EHR and written) arenot reflective of routine hospital policies for the documentation of pressure ulcers.Education related to the use of the EHR for pressure ulcer documentation shouldbe reinforced among nurses. In addition, a need exists for guidelines to standard-ize and routinely evaluate EHR documentation in clinical practice.

computer-based nursing documen-tation system, and legal require-ments for documentation were ful-filled.

Pressure UlcersPressure ulcers are costly. In

Maryland, where pressure ulcers areregarded as hospital-acquired com-plications, the incremental cost was$17,495 per case in fiscal year 2008(Fuller, McCullough, Bao, & Averill,2009). Other authors documentedincreased costs of $2,384 per case(Pappas, 2008). This includes addi-

tional nursing time, supplies fordressings, medications, nutritionalservices, and physician fees. Be-ginning on October 1, 2008, theCenters for Medicare and MedicaidServices (2007) implemented a 0%complication rate for a number ofclinical diagnoses, including a stageIII and IV pressure ulcer acquiredduring a hospitalization. This rulinghas led hospitals throughout thecountry to emphasize pressure ulcerprevention and improve under-standing of risk for hospital-acquiredpressure ulcers because prevention ismore cost effective than treatment

(Alderden, Whitney, Taylor, &Zaratkiewicz, 2011). Schuurman andcolleagues (2009) conducted a studyto determine the cost for preventionand treatment of pressure ulcersfrom a hospital perspective. Findingsindicated the same intervention(repositioning, mobilization) is moreexpensive in the treatment groupthan in the prevention group as ittakes more nursing time to performthe intervention in patients withpressure ulcers. These results are con-sistent with other studies (Padula,Mishra, Makic, & Sullivan, 2011;Richardson, Gardner, & Frantz,1998).

Documentation of PressureUlcers

Part of the solution to the problemof pressure ulcers was the provisionof guidelines. According to 2007National Pressure Ulcer AdvisoryPanel (NPUAP) guidelines, initialassessment of pressure ulcers includesthe location, stage, measurement,presence of sinus tracts, undermin-ing, tunneling, exudates, and necrot-ic tissue. To evaluate healing, a sys-tematic and routinely scheduledreassessment is necessary. Documen-tation of pressure ulcer reassessmentmust be completed periodically andrecorded, preferably on a table orchart. According to the guidelines,pressure ulcers should be describeduniformly to facilitate communica-tion among staff and ensure adequatemonitoring of progress toward heal-ing. To determine adequacy of thetreatment plan, caregivers must mon-itor pressure ulcers at consistent inter-vals. Assessment and documentationshould be conducted at least everyshift, unless there is evidence of dete-rioration, in which case both the pres-sure ulcer and patient's overall man-agement must be reassessed immedi-ately.

Frequently, documentation amongproviders is inconsistent and can leadto a delay in proper treatment of theulcer. Previous studies demonstrateddocumentation of pressure ulcers isinadequate. One retrospective study(Pieper, Mikols, Manee, & Adams,1990) of 167 charts compared infor-mation recorded in nurses' notes to

18 lanuary-February 2013 • Vol. 22/No. 1 M E D S U R G

Determination of the Effectiveness of Electronic Health Records to Document Pressure tJlcers CNEthe standards of wound care. Nurses'notes were examined for documen-tation of pressure ulcer location,color, wound measurement ordescription of size, drainage charac-teristics, odor, evidence of healing,and the nature of the surroundingtissue. Results demonstrated docu-mentation did not adhere to thestandards. Only 16.86% of the notescontained actual wound measure-ment and 20.05% had size descrip-tions. Only 12.64% described evi-dence of healing.

Gunningberg, Fogelberg-Dahm,and Fhrenberg (2009) found lowaccuracy in nurses' and physicians'documentation of pressure ulcerswhen compared with the physicalexamination of patients. Descripfionsof wound size and other characteris-tics were fiawed, assessments werenot documented correctly, and pres-sure ulcer prevenfion strategies wererecorded poorly. Comprehensivenesswas lacking in the documentafion ofpressure ulcer care.

Stremitzer, Wild, and Hoelzenbein(2007) sought to determine the vari-ability and accuracy of assessment byphysicians and nurses working withpatients with chronic wounds.Results showed documentation ofwound size and depth variedbetween physicians and nurses forthe same ulcer. In an effort todecrease the rate of hospital-ac-quired pressure ulcers, Ballard andcolleagues (2008) conducted a studyto develop a focused, aggressive planto reduce the rate of hospital-acquired pressure ulcers in intensivecare settings. Researchers first exam-ined nurses' assessment and docu-mentation. Results revealed routineskin assessments and documenta-tion were inconsistent. One strategywas to redesign risk assessment anddocumentation by developing awound chart similar to a medicationadministration record (MAR). As aresult, the nurses were able to chart acareful skin assessment on thewound MAR upon patient admis-sion.

Documentation is critical indefending nurse actions and deter-mining if the standard of care wasprovided to a patient. The obligationto document care is a legal one that

includes patient safety issues. In acourt of law, the patient's healthrecord serves as the legal record ofthe care or service provided. Apartfrom the provision of patient care,high-quality documentation canhelp nurses to exchange informationabout their patients' health status.Clear nursing documentation in-cludes the background of care, diag-nosis, planned and performed inter-ventions, and patient education(Saranto & Kinnunen, 2009).

Problem StatementPoor pressure ulcer documenta-

tion can cause significant humanand financial costs associated withthe occurrence of pressure ulcers.Limited documentation or absenceof ongoing documentation of theskin assessment can result in alengthened hospital stay, potentiallyincreased pain due to lack of treat-ment, increased cost due to theincrease in complications or conse-quences, and increased humanresources to care for the skin break-down once it advances. Pressureulcers reduce quality of life and posea considerable worldwide economicquandary (Pham & Stern, 2012).

Pressure ulcer treatment requiresconsistent objective assessments anddocumentation for proper treatmentto be maintained. In many instances,providers' documentation varies orthere is inadequate documentationregarding wound condition, treat-ment, and preventive measures.These deficiencies have conse-quences for the quality and safety incare because errors could occur andcontinuity of patient care may behampered. Patient records need torefiect valid, reliable data on pressureulcers and actions taken for preven-tion and treatment. However, a smallbody of literature (Abramson et al.,2011; Borycki, Kushniruk, Kuwata, &Kannry, 2011; Zlabek, Wickus, &Mathiason, 2011) provides prelimi-nary evidence of the impact of anEHR on the provision of safe, qualitycare to hospitalized patients. Fewstudies specifically focused onimpact of the EHR on health care-related outcomes, specifically pres-sure ulcers (Cunningberg, Dahm, &

Ehrenberg, 2008; Gunningberg et al.,2009). Therefore this pilot study willtrack the EHR documentation ofpressure ulcers on a medical-surgicalunit.

Methods

Subjects and SettingThis pilot study was completed at

a 560-bed medical center in Miami,FL. A convenience sample of med-ical-surgical patients enrolled in alarger study related to pressure ulcersupport mattresses was used. Of the139 patients enrolled in the study, 60had medical diagnoses and 79 weresurgical pafients. Participants, includ-ing 81 women and 58 men, had amean hospital length of stay of 5.5days. All eligible patients met the fol-lowing criteria: (a) weighed morethan 70 pounds but less than 500pounds, (b) remained on the mat-tress for a minimum of 2-10 days,and (c) admitted to the hospital for amedical diagnosis or surgical proce-dure. Permission to complete thestudy was approved by the institu-tional review board at the Universityof Miami and all EHRs were readilyaccessible to the investigators.

Instrumentation and DataCollection

A chart audit form was developedby the researcher and used to reviewdocumentation for each of theenrolled patients (see Figure 1). Onegraduate nursing student performedthe paper-based record audit withthe guidance of the project coordina-tor. One researcher and one graduatenursing student independentlyaudited electronic records for thepresence of pressure ulcers. Datawere collected daily from the EHRfor each patient and included thefollowing: (a) current score on theBraden Scale for Predicting PressureUlcer Risk and (b) skin assessmentand wound assessment documenta-tion. To compare the documentationbetween the EHR and the paper-based record, a paper-based chartreview was conducted for the samegroup of patients.

Nursing documentation from theEHR was reviewed to identify any

MEDSURG January-February 2013 • Vol. 22/No. 1 19

CNEFIGURE 1.

Chart Audit Form

EHR Audit Written Record Audit

Wound site:Dressinq tvpe:

Dressinq status:

Assessment deferred until dressing change:

Wound tvpe:Granulation:

Hardeninq around wound:Wound odor:Wound color:

Drainaae amount:

Drainaae color:Measured: date: L(cm): W(cm): D(cm):

Staqinq assessment:

Pressure ulcer stage:

Phvsician notified: Date notified:Photo taken: Date taken:Comment:

Location:

Wound type: ("CZ>"below)

Pressure ulcer: Staae

Arterial Venous Diabetic SurgicalOther:

Size (cm) (LxW): Depth (cm):

Tunnelina (cm):Underminina (cm):

Data first observed: Granulation:Exúdate: ("CZ)"below)

Odor: None Slight Moderate FoulType: None Bloody SerosanguineousPurulenfFoul

Wound bed: ("CZ5"below)Normal for skin SloughPink/beefy red tissue Black/Brown (eschar)Granulation tissue

Surrounding skin color: ("CZ3"below)Normal for skin White/Gray pallorPink Dark red/PurpleBright red Black/Brown

Wound edges/surrounding tissue: ("O"below)Normal for skin Hardness/IndurationPeripheral tissue edema Rolled edgesMaceration

Photo taken date:Wound location circled: ("C3"below)

Yes No

notes about pressure ulcers. If nurs-ing notes were written, the audit wascompleted using the audit instru-ment. All written medical recordswere reviewed for admission assess-ment notes, progress notes, woundphotographs, and any nursing notespertaining to pressure ulcers. If pho-tographs were available, they werecopied to a digital disk. Patientrecords (EHR and written medicalrecord) were independently com-pared to the hospital's wound carepolicy. The current hospital woundcare policy read as follows:• An assessment of each patient

and documentation upon admis-sion, every shift, and at dischargefor potential or actual impaired

skin integrity should be recorded.• All patients with community-

acquired and/or health care-acquired wounds will have thewounds isolated and pho-tographed to establish a baselinemeasure of the wound's appear-ance and location, and to docu-ment the progression of thewound. Photographs of all skinalterations will be taken onadmission, every Wednesday,and on the day of discharge.

Data AnalysisDescriptive data were analyzed

using the Statistical Package for theSocial Sciences Version 17.0 for

Windows. The NPUAP classificationsystem (see Table 1) for physicalexamination of patients was used todetermine the staging of pressureulcers during audits.

ResultsEight EHRs and seven wrirten

medical records were identified withnursing notes about pressure ulcers.Of those, only four cases of pressureulcers were documented on the samepatient. Four pressure ulcer docu-mentations in the EHR were notidentified in written medical records,while three pressure ulcer documen-tations in written medical recordswere not identified in the EHR.

20 lanuary-February 2013 • Vol. 22/No. 1 M E D S U R Gisr t j i^ s I :isr G

Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers CNETABLE 1.

National Pressure Ulcer Advisory Panel (NPUAP) Classification System

Suspected DeepTissue Injury

Stage I

Stage II

Stage III

Stage IV

Unstageable

Sign and Symptoms

Purple or maroon localized area of discolored intact skin orblood-filled blister due to damage of underlying soff tissue frompressure and/or shear. The area may be preceded by tissuethat is painful, firm, mushy, boggy, warmer, or cooler ascompared fo adjacent tissue.

Infacf skin with non-blanchable redness of a localized areausually over a bony prominence. Darkly pigmented skin maynot have visible blanching; ¡ts color may differ from thesurrounding area.

Parfial-fhickness loss of dermis presenting as a shallow openulcer wifh a red pink wound bed, without slough. May alsopresent as an intact or open/ruptured serum-filled blister.

Full-thickness tissue loss. Subcutaneous fat may be visible butbone, tendon, or muscle are not exposed. Slotjgh may bepresent but does nof obscure the depth of tissue loss. Mayinclude undermining and tunneling.

Full-thickness tissue loss wifh exposed bone, tendon, ormuscle. Slough or eschar may be present on some parts of fhewound bed. Often include undermining and tunneling.

Full-fhickness tissue loss in which the base of the ulcer iscovered by slough (yellow, tan, gray, green, or brown) and/oreschar (fan, brown, or black) occurs in fhe wound bed.

Source: NPUAP, 2007.

Quality of Written Recordsof Pressure Ulcers

The overall quality of nursingdocumentation for pressure ulcerswas poor. Of the 139 patient records,seven had photographs of thewound and its location. However,the size of the pressure ulcers was notdocumented. One record had nodescription of the wound except thelocation, and two cases had nodescription of the size or depth ofthe wound.

Quality of EHRDocumentation of PressureUlcers

Numerous deficiencies were notedin the EHR documentaüon for pres-sure ulcers. Of the eight records withdocumentation of pressure ulcers,none were consistent. For example, inone record, documentation was iden-tified for 16 days; however, only oneassessment was described as a stage IIpressure ulcer, with all the other notesshowing either a non-pressure-related

ulcer or no documentation at all.Other discrepancies in documenta-tion were seen in most of the otherrecords. For instance, some nursesdocumented pressure ulcers on theincision template. There was no tem-plate for descriptions of pressureulcers. Therefore, even though nursesrecorded the presence of pressureulcers, they did not provide a thor-ough description of staging or size ofthe pressure ulcers. In addition,researchers observed night shift nurs-es documented more poorly than dayshift nurses when comparing eachcategory of pressure ulcer documenta-tion (see Table 2). For example, thelocation of pressure ulcer was docu-mented 48 times in day shift; whilethe location was documented threetimes in night shift. Wound color ofpressure ulcer was documented 30times in day shift, while only 13 timesin night shift. However, each catego-ry of pressure ulcer should be docu-mented 91 times in both day shiftand night shift.

Nursing DocumentationComparison: EHR vs. WrittenRecord

Four records in the EHR indicatedthe presence of pressure ulcers, butno photographs were available inthe written medical record or specif-ic information in the paper-basedrecords. Conversely, three photo-graphs of pressure ulcers were foundin written medical records but noevidence of documentation in theEHR. Eleven patients with pressureulcers were identified either by theEHR or written record (see Table 2regarding use of the EHR). The totalhospitalization was 91 days, whichincluded both day shift (7:00 a.m. to7:00 p.m.) and night shift (7:00 p.m.to 7:00 a.m.). Fifteen cases of pres-sure ulcers were identified. Fourpatients had two pressure ulcerswhile others had one pressure ulcer.Therefore, pressure ulcer descrip-tions, which included location, size,stage, granulation, wound color,wound odor, drainage amount,wound edges/surrounding tissue,tunneling, undermining, dressingstatus, physician notification, andphoto taken, should have been doc-umented 254 times. However, themost frequent recording was thelocation of pressure ulcers (83 times).The second most ftequent recordingwas the dressing status (69 times).The other aspects of pressure ulcerdescriptions only were recorded 0-43times. Photographs taken to docu-ment the wound did not track thehealing progress of the wound.Based on the same group of patientsand the hospital wound policy, pho-tographs should have been enteredin the medical record 45 times.However, only 10 photographs werefound in the written records and thewound description in all 10 writtenrecords was lacking.

DiscussionFindings demonstrated documen-

tation of pressure ulcers was incom-plete or inaccurate in both the EHRand the written medical record. Themost frequent incongruences includ-ed the location, appearance, and sizeof the pressure ulcers; and the fre-quency of recording or assessing the

MEDSURG January-February 2013 • Vol. 22/No. 1 21

CNETABLE 2.

Nursing Documentation for All Pressure Ulcers

Day Shift(7:00 a.m. to7:00 p.m.)

Night Shift(7:00 p.m. to

7:00 a.m.)

DocumentationTotal Pressure Written Record in EHR as an

Uicers Documented incision vs.Documented Photos (n=11) Pressure Ulcer

* Some patients have documentation for two pressure ulcers on each shift.** The total number of pressure ulcer cases was 15.

Required Number of PressureUlcer Documentations

Pressure U l c ^ ^ ^ ^ ^ ^ ^ ^

Location

Size

Stage

Granulation

Wound color

Wound odor

Drainage amount

Wound edges/surrounding tissue

Tunneling

_ Undermining

Dressing status

Photo taken

Physician notified

91

•JIIM48

0

9

"126"30

22

19

22

0

0

36

3

4

91

• • • •35

0

7

13

11

10

10

0

0

33

4

4

254*

• • • •83

0

16

41

43

33

29

32

0

0

69

7

8

45

• • • 110

0

6

Ó

8

7

4

5

0

0

10

0

! _ _ _ _

5

0

0

0

„ „ ^ ^ 00

0

0

^̂ .̂̂ _̂0_

5

0

0

patient risk. Neither the EHR nor thewritten medical record providedthorough data on pressure ulcers.

According to the 15 cases of pres-sure ulcer identified through thisstudy, the photography of pressureulcer appearance should be done 45times in the written medical record.However, only 10 photos were foundin the written medical record. Theuse of photography by health careproviders to document pressureulcers should be the preferredmethod to assess wound size andevaluate treatment. The use of digitaltechnology/photos can help clini-cians evaluate the healing processesof pressure ulcers (Rennert, Golinko,Kaplan, Flaftau, & Brem, 2009).

Authors determined all nursingstaft members who took the picturesdid not measure the wound (seeFigure 2). The NPUAP stronglyencourages that a pressure ulcer pro-tocol include clear patient identifica-

tion, date and time of the photo,markings for a sample measure (e.g., a10 cm strip of paper tape) in eachframe, and that the photographsbecome part of the medical record(European Pressure Ulcer AdvisoryPanel and National Pressure UlcerAdvisory Panel, 2009). Additionally,although the current hospital policyrequires photographs of all wounds tobe taken on patient admission, everyWednesday, and on day of discharge,all seven wriften medical records withidentified pressure ulcers had onlyone picture during the whole hospi-talization. Thus, pressure ulcer heal-ing processes were not evident andwound treatment was not recorded.The lack of consistent photographsinhibited researchers' ability to auditfor pressure ulcer wound healingassessments. Thus, serial digital pho-tography should be used more fte-quently to track pressure ulcers forhealing or treatment processes.

A discrepancy existed in the EHRon evaluation of presence of pressureulcers among difterent nurses. Fivenurses documented redness or skinrash instead of stage I pressure ulcerin the wound description template.However, other nurses documentedstage I pressure ulcer for the samepatient. These inaccuracies may beexplained by the nurses' lack ofknowledge about the signs of earlytissue damage or the importance ofmaintaining skin integrity. Thesefindings are consistent with reportsby Gunningberg and Ehrenberg(2004). They also found the qualityof nursing documentation lackedaccuracy in assessing stage I pressureulcers.

Authors found the required num-ber of pressure ulcer documentationswas not in accordance with the actu-al number of pressure ulcer docu-mentations. For example, based onthe 15 cases of pressure ulcer discov-

22 lanuary-February 2013 • Vol. 22/No. 1 M E D S U R G

Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers CNEFIGURE 2.

Example of Pressure Ulcer Photos Taken by Nursing Staff*

Stage 1Pressure Ulcer

stage 2Pressure Ulcer MMÉi'iii[i.iiii,iiiii,iiin,ii,inin||i

Stage 3Pressure Ulcer

Not documented with a sfrip of paper tape measurement.

ered in this study, the required num-ber of pressure ulcer documentationsfor characteristics of pressure ulcersshould be 254. However, the loca-tion of the pressure ulcers was onlydocumented 83 times; similarly, thesize of pressure ulcers had zero docu-mentation. Perhaps one explanationfor missing documentation may bethat nurses assessed patients andgave verbal report during shiftchanges. Also, possibly descriptivepressure ulcer charting is neglectedbecause of the time it takes, especial-ly with increased patient acuity andthe nursing shortage. In addition, itmay indicate deficient knowledge oran inability to express basic nursingcare in writing. Yet, for legal implica-tions as well as effective monitoringand treatment of pressure ulcers,accurate and complete documenta-tion of pressure ulcers is critical(Florczak et al., 2012).

Other results showed night shiftnurses had less documentation foreach characteristic of pressure ulcerscompared to day shift nurses (loca-tion, stage, granulation, woundcolor, wound odor, drainage amount,wound edge/surrounding tissue, anddressing status). Perhaps this is due to

chronic sleep deprivation of nightshift staff which can have significantnegative effects on job performanceand social functioning (de Cordova,Phibbs, Bartel, & Stone, 2012; Smith,Cullnan, & Eastman, 2008). Finally,findings showed five nurses docu-mented pressure ulcers on the inci-sion page in the EHR. That is, theywere not familiar with the electronicforms for pressure ulcer documenta-tion. The use of an EHR is moreimportant for improving qualitythan its presence or absence. That is,adopting an EHR alone is insufficientto improve quality (Blair & Smith,2012; Kelley, Brandon, & Docherty,2011). Instead, nurses must be famil-iar with the function and use it cor-rectly to increase the quality of docu-mentation. Thus, an expert in nurs-ing informatics may be needed toeducate staff nurses periodically toassure they document accurately inminimal time. It is also possible thatelectronic assessment forms are notdesigned correctly based on profes-sional nursing organization stan-dards. Thus, an expert team thatunderstands system functionally,data requirements, workflow process,and nursing process are essential

when designing or redesigning anelectronic record. Barthold (2009)and Douglas (2001) suggested acouncil based on Magnet® criteria beused fo define the standards; thecouncil should be chaired by a staffnurse who will assist in the design ofthe electronic forms with the appro-priate data elements.

The shortcomings of the EHR andwritten records highlight the needfor specific standardized guidelinesto record pressure ulcers. Increasingthe accuracy of data collection toidentify the early signs of pressureulcers will improve the quality ofcare for hospitalized patients.Increased education and training toImprove staff nurses' knowledge arehigh priorities to improve clinicalpractice. Accurate documentation isa prerequisite for patient safety andworkflow efficiency, and it helpsthe nurse provide better care(Gunningberg & Ehrenberg, 2004;Stevens & Milne, 2007).

Future StudyThe most important findings

were the identification of inaccura-cies in the documentation of près-

MEDSURG isr xj II s I jsro. lanuary-February 2013 • Vol. 22/No. 1 23

CNEsure ulcer in both the EHR and writ-ten medical record. A large studyshould be performed across all caresettings in the United State to allowmore thorough evaluation of prob-lems of pressure ulcer documenta-tion. In addition, this pilot studyprovided valuable insights for futurestudies. The results revealed somenurses were not familiar with thetemplate in the EHR. A future studymay focus on discovering the factorsand barriers faced by nurses duringuse of the EHR. This would providemore information to improve thequality of nursing documentation.

LimitationsAlthough the sample size was

small (N=139), it did allow identifica-tion of inaccuracies in the EHR andwritten record. The sample, whichincluded only medical and surgicalpatients, lacked a variety of patientsfrom different departments. There-fore, generalizability of the findingswas limited. Regardless of these limi-tations, findings shed light on theissue of pressure ulcer documenta-tion in health care settings and thefactors that impact the problem.Additionally, researchers were able todescribe the need to improve thequality of pressure ulcer documenta-tion and demonstrated the need toincrease patient safety, enhanceworkfiow efficiency, and help nursesprovide better care.

Nursing ImplicationsFor optimized efficiency of the

EHR documentation in patient care,it is not only important to include allnursing forms but also to ensure theelectronic system is aligned withnurses' documentation practice.Continuous education and mentorsupport are essential to ensure nurs-es' effective usage of the EHR.

Nursing InformaticsImplications

Even though this study has limit-ed generalizability to other healthcare sites, findings may have impli-cations for supporting nurses' in-volvement in EHR design. The mostimportant role for nurses in the

24

design of EHRs is to deliver theessential nursing content to EHRdevelopers. Based on the result of thecurrent study, EHR developers canwork with direct-care nurses to facil-itate a computerized environmentthat supports nursing workflow. Thepurpose for nurses' participation inEHR development is to enhancenursing practice and patient out-comes by assisting EHR developers tointerpret correctly the meaning ofdomain content by clarifying anyambiguity in domain content repre-sentation, and verify newly devel-oped modes of documentation(Blavin, Buntin, & Friedman, 2010).

Nursing EducationImplication

The findings may have implica-tions for creating teaching modulesfor undergraduate nursing studentsand staff nurses. For instance, themodules can give a picture of thewound, and the nurse or student canbe asked to examine and assesswound characteristics. After initialexamination, the student or nursecan be asked to document woundcharacteristics in the designed EHR.An essential goal for using simula-tions in teaching is to mirror the realworld in a safe environment thatsupports learning from mistakes andallows for error. A simulated scenariothus should be as close as possible tothe clinical reality for students ornurses to allow transfer of skillslearned in the academic setting intoa practice environment (Rutherford-Hemming, 2012). The results of thecurrent study could be helpful forcreating different scenarios.

ConclusionThe results of this pilot study

illustrated neither the EHR nor writ-ten patient records are reflective ofroutine hospital policies for the doc-umentation of pressure ulcers.Education related to the use of EHRfor pressure ulcer documentationshould be reinforced among nurses.In addition, guidelines are needed tostandardize and routinely evaluateEHR documentation in clinical prac-

January-February 2013 • Vol. 22/No. 1

Instructions ForContinuing Nursing

Education Contact HoursDetermination of the

Effectiveness of ElectronicHealth Records to Document

Pressure Ulcers

Deadline for Submission:February 28, 2015

MSN J1302

To Obtain CNE Contact Hours1. For those wishing to obtain CNE con-

tact hours, you must read the articleand complete the evaluation throughAMSN's Online Library. Completeyour evaluation online and print yourCNE certificate immediately, or later.Simply go to www.amsn.org/library

2. Evaluations must be completed onlineby February 28, 2015. Upon completionof the evaluation, a certificate for 1.4contact hour(s) may be printed.

Fees - Member: FREE Regular: $20

ObjectivesThis continuing nursing educational (CNE)activity is designed for nurses and otherhealth care professionals who are interest-ed in electronic health record (EHR) docu-mentation. For those wishing to obtainCNE credit, an evaluation follows. Afterstudying the information presented in thisarticle, the nurse will be able to:1. Describe the development of the EHR.2. Identify issues related to inconsistencies

with documentation of pressure ulcers.3. Discuss a study examining nursing doc-

umentation of pressure ulcers from theEHR.

4. Explain the nursing implications of theEHR documentation in patient care.

Note: The authors, editor, and educationdirector reported no actual or potentialconflict of interest in relation to thiscontinuing nursing education article.

This educational activity has been co-providedby AMSN and Anthony J. Jannetti, Inc.

Anthony J. Jannetti, Inc. is a providerapproved by the California Board of RegisteredNursing, provider number CEP 5387. Licenseesin the state ot CA must retain this certificate forfour years after the CNE activity is completed.

Anthony J. Jannetti, Inc. is accredited as aprovider of continuing nursing education by theAmerican Nurses' Credentialing Center'sCommission on Accreditation.

Accreditation status does not imply endorse-ment by the provider or ANCC of any commercialproduct.

This article was reviewed and formatted fort contact hour credit by Rosemarie Marmion,^MSN, RN-BC, NE-BC, AMSN EducationDirector. Accreditation status does not implyendorsement by the provider or ANCC of anycommercial product.

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