La validez de un registro clínico de úlceras por presión

Abstract

Background. To compare pressure ulcers (PU) found in this prospective observational study with PU recorded in the Electronic Medical Record (EHR). Method. We use a prospective observational study to record PU, with daily monitoring by an observer in the medical- surgical units of hospitalization, as well as a clinical record review of PU tracking. Patient monitoring was conducted between December 2008 and March 2009 at Fuenlabrada University hospital. We calculated the absolute and relative frequency of PU in the patients followed, as well as the association among qualitative variables and the validity of the registration in the EHR with regard to the reference standard, the observational study. Results. Among the 1, 001 patients followed-up in this study, 42 of them showed PU (4.2% of the total patients), compared to 25 (2.5%) patients who had registered PU in the Electronic Health Record, which means a statistically significant difference (p<0.001). The record of PU presents a Kappa index of 0.548, with a sensitivity of 47.62 % and a specificity of 99.48 %, with regard to the reference standard, the observational study. Conclusion. The number of patients with pressure ulcers almost doubled if the observational data collection is done by an expert nurse compared to what was recorded in the EHR.