Documentation of Preventive Nursing Measures in the Elderly Trauma Patient: Potential financial Impact and the Health Record.

Abstract

Hospital-acquired complications in older adults are significantly higher than in younger patients. Nursing measures to prevent hospital-acquired complications are generally mandated by nursing policy and are required documentation in hospital record systems. In this study, gaps in the nursing documentation of measures intended to prevent hospital-acquired complications in elderly trauma patients may be related to the documentation of these measures not being required entries in the system used by the facility. These findings highlight the importance of the relationship between nursing documentation requirements and the system used for the expedient documentation of nursing care.