Documentation of bedsores, comment

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As a wound care champion at my place of work, l got excited reading the original post on bedsore docs. Most hospitals are anal about Hospital Acquired Pressure Ulcer, (HAPU). In dealing with hapu, nurses have to do a thorough investigation on assessment once we get new admits. In the past, patients who are triaged in the emerg room are often not properly assessed leaving room for errors while the floor nurses have to pick up the slack. Once at a meeting, most nurses were amazed at a case where a patient had about 10mm open sore which was never documented. The hospital lost their reimbursement because it was treated as HAPU rather than CAPU (community acquired pressure ulcer.) In quality management, our hospital decided to collect nursing volunteers who will meet monthly to act as buddies to other nurses while doing initial assessment. This has paid off because for the past year, we did not record any HAPUs .

Original Post:
June 17, 2009
Title: Documentation of Bedsores
Joint Commission and CMS (Medicare) has set a Patient Safety Goal of not allowing bedsores to occur during hospitalizations. My institution uses technology to document existing wounds at the time of admission assessment. We are a totally computerized charting hospital. When we identify an existing wound, we bring up a screen of the body and insert a photo of the wound into the patient’s medical record. This feature allows us to prevent lawsuits and receive the correct reimbursement of that patient’s hospitalization. Health assessment no longer has to rely on a verbal or hand written dictation to describe history and physical assessments!

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