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Accuracy in documentation – a study of peripheral venous catheters
Author(s) -
Ahlqvist Margary,
Berglund Britta,
Wirén Mikael,
Klang Birgitta,
Johansson Eva
Publication year - 2009
Publication title -
journal of clinical nursing
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.94
H-Index - 102
eISSN - 1365-2702
pISSN - 0962-1067
DOI - 10.1111/j.1365-2702.2008.02778.x
Subject(s) - documentation , medical record , medicine , logistic regression , lumen (anatomy) , emergency medicine , surgery , computer science , programming language
Aim. The aim was to explore the extent of postinsertion documentation of peripheral venous catheters (PVCs) in patients’ medical records, including the descriptions used to explain the PVC insertion site and determinants of PVC documentation. Background. Documentation in medical records is an important precondition for the safe handling of patients PVC. However, factors associated with documentation of PVCs and how the insertion site is described in medical records has not previously been studied. Design. This was a cross‐sectional and descriptive study. Methods. A sample of 933 adult inpatients (women 45·7%) with PVC was recruited from medical and surgical wards at one university hospital and two general hospitals. A data collection form was used for registration of the insertion site of the PVC, hand side, lumen size, patient’s age and gender. PVC documentation from medical records was transcribed. Factors associated with the documentation were analysed using logistic regression. Results. Ten descriptions used to explain the insertion site of the PVCs were identified in the patients’ medical record. Any kind of PVC documentation was found in 71·8% and documentation that included insertion site, hand side and lumen size was recorded in 46·2% of the observed PVCs. Multivariate logistic regression revealed that PVC documentation was associated with medical wards at general hospitals (OR 4·59; 95% CI 3·10–6·81; p < 0·0001) and smaller lumen size (22 gauge) (OR 1·81; 95% CI 1·19–2·84, p = 0·006). Conclusion. The extent of PVC documentation in medical records was low and descriptions used to explain the PVC insertion sites were found to vary appreciably. General hospitals and in particular medical wards and smaller lumen size, were associated with PVC documentation that included insertion site, hand side and lumen size. Relevance to clinical practice. Development of terms is needed to assure standardisation of postinsertion PVC documentation. Education of nurses on proper PVC documentation should be given priority.