Key result
Analysis of 80 medical records following open heart surgery showed that physical wellbeing was dominantly documented, whereas psychological and social aspects were moderately or rarely documented.
Population
80 medical records of patients in the first five months following open heart surgery
Follow-up
first five months after surgery
Authors
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Documentation gaps may limit holistic post-open heart surgery care; hypothesis-generating for improved nursing record standards.
Observational (n=80)
Medical records of patients following open heart surgery predominantly focus on physical wellbeing, inadequately reflecting psychological and social aspects of patient health.
Karlsson et al. (2012) conducted an observational in Open heart surgery (n=80). Documentation of patient wellbeing was evaluated on Documentation of patient wellbeing (physical, psychological, and social aspects). Analysis of 80 medical records following open heart surgery showed that physical wellbeing was dominantly documented, whereas psychological and social aspects were moderately or rarely documented.
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