Validation of nursing documentation regarding in-hospital falls: a cohort study

Abstract Background In-hospital fall incidents are common and sensitive to nursing care. It is therefore important have easy access valid patient data evaluate follow-up The aim of the study was validate documentation, using a specific term in registered nurses´ (RNs´) discharge note, regarding inpatient falls according outcome digitalized extraction tool note itself. Methods At teaching hospital, 31,571 episodes care were eligible for inclusion this retrospective cohort study. A stratified sampling including five groups used, two with random three total sampling. In total, 1232 reviewed electronic record study-specific protocol. Descriptive statistics used. Results 590 included 714 falls. When adjusted cumulative incidence population 1.9%. positive predictive value presence any fall, comparison review, 87.4%. Discrepancies found were, example, that RNs, at discharge, stated had fallen but no documented evidence could be detected during admission. also opposite, RNs correctly occurred, made an incorrect selection. latter been withdrawn, 91.5%. Information about minor injuries due less accurate. group where without injury, actually occurred 28.3% Conclusions use RNs´ seems reliable measurement can used continuously