Healthcare Informatics Resources

I found this post and other comments relative to my new nursing job. As an experienced ER nurse, we found little time to assess or document pressure ulcers. With the new CMS guidelines that came out this past October, Medicare will not longer be reimbursing for facility acquired pressure ulcers. My new nursing role focuses on prevention and education. I was very surprised how little I knew about pressure ulcers from working in the ED. Yet it is so vital that our assessment starts there. The photo proof documentation mentioned in this Post sounds like an excellent idea. One of the hospitals I work with, just installed a whole new soft ware program for nursing documentation. It is really easy to chart your skin assessments and pressure ulcers. With drop down choices, body diagrams. But the wound care nurse still has to validate the floor nurses documentation with her own patient assessment every month. I helped her with this, and it was very time consuming. It was double the work in my eyes. Yet we did find, many pressure ulcers that were resolved and many that were staged incorrectly, as well as several that were missed by the RN. Even though we have many different technologies to help us with our documentation and assessment, it still comes down to basic education.

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!

Tags: Healthcare Informatics, Healthcare Informatics Resources, bedsore decubitus ulcer assessment documentation, Pressure ulcer documentation, Nursing Health Assessment

This entry was posted on July 31, 2009 at 1:06 pm and is filed under Computer Charting, Health Assessment. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.