LAUSR

AIM To evaluate the completion of nursing records through scheduled audits to analyse risk outcome indicators. BACKGROUND Nursing records support clinical decision-making and encourage continuity of care, hence the importance of auditing their completion in order to take corrective action where necessary. METHOD This was an observational descriptive study carried out from February to November 2020 with a sample of 1,131 electronic health records belonging to patients admitted to COVID-19 hospital units during three observation periods: pre-pandemic, first wave, and second wave. RESULTS A significant reduction in nursing record completion rates was observed between pre-pandemic period and first and second waves: Braden scale 40.97%, 28.02%, and 30.99%; Downton scale: 43.74%, 22.34%, and 33.91%; Gijón scale: 40.12%, 26.23%, and 33.64% (p<0.001). There was an increase in the number of records completed between the first and second waves following the measures adopted after the quality audit. CONCLUSIONS The use of scheduled audits of nursing records as quality indicators facilitated the detection of areas for improvement, allowing timely corrective actions. IMPLICATIONS FOR NURSING MANAGEMENT Support from nursing managers at healthcare facilities to implement quality assessment programmes encompassing audits of clinical record completion will encourage the adoption of measures for corrective action.