Documentation of the treatment of pressure ulcers in home care agencies and welfare institutions in the Slovak Republic

Abstract

Objective: To analyze the documentation of pressure ulcers at home care agencies (HCA) and welfare institutions (WI) to determine whether the records comply with legislative and contractual requirements. Methods: Empirical data were collected from the documentation containing the Nursing Care Proposal (Proposal), the Course of disease, the Expert Findings, and the Records of examinations and prescription drugs for the treatment of pressure ulcer in the Health Insurance Information System (HIIS). Data collection was carried out from the year 2014 to 2018. Documentation of 101 patients treated for pressure ulcer which were reported to the General Health Insurence Company, a.p. (GHIC) for paymant, were included in the research file. Descriptive, frequency analysis methods were used to evaluate the results. Results: Correct recording of localization, size, number and codes, less consistent writing of base, margins, secretion, and pressure ulcer surroundings. The analysis pointed to shortcomings in documenting continuous information on the pressure healing process and the diversity in the frequency of documenting the pressure ulcer healing process. 65.3% of the patients were treated by a specialist. The identity of the drugs reported in the HCA/WI documentation with the drugs reported in the HIIS was 46.5%. Conclusions: Problems in recording nursing care of pressure ulcers are mainly in the area of unstructured records of pressure ulcer healing process and in the uniformity of recorded information on applied drugs in nursing documentation and in HIIS.