Documentation of Bedsores, comment

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The hospital where I currently work also includes documentation of existing pressure ulcers on admission of a patient. However, the protocol asks you to assess the patient’s skin then to document on paper what the ulcer looks like, stage, size, drainage, etc. The paper charting does not require a picture of the pressure ulcer that was found by assessment of the RN. I think this leaves a wide margin for error. It is probable that some ulcers will not be documented correctly. I believe that a photo would be advantageous to the medical record along with perhaps a computerized charting system where you can label with an X any area of the body that has breakdown and then attach a photograph to the document. Also the documentation I work with does not allow for updates on how the pressure ulcer heals or worsens. This also leaves room for criticism and error. I think my place of work would benefit from photo/computerized documentation of pressure ulcers.

Original Post:
July 31, 2009
Title: Documentation of Bedsores, comment

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!

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2 Responses to “Documentation of Bedsores, comment”

  1. Meble Says:

    Wow! This could be one particular of the most helpful blogs We have ever arrive across on this subject. Actually Wonderful. I am also an expert in this topic so I can understand your hard work.

  2. usindo1 Says:

    A photograph is good as it demonstrates specific viewing of the site. However, for quantifiable documentation purposes perhaps your hospital or nursing home can use the TempTouch dermal thermometer which facilitates reading temps on a patient’s skin. By comparing and contrasting the temps e.g. right heel vs. left heel, one can detect gradations in temperatures. In this way the patient serves as their own control.

    Anytime the temperature on a contralateral side is >4ºF then the patient has an inflammation that could continue to become an ulcer. That is what the TempTouch’s intended use is! It may be of use to you. TempTouch is made by Diabetica Solutions in San Antonio, TX. They have several clinical trials reported in major clinical journals.

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