Documentation on Bedsores, comment


When performing a skin assessment the obvious places to look for pressure ulcers are the sacrum, elbows, and heels. We can not forget to look in the unlikely places, such as the back of the head, ear lobes and around an ET tube. Doing many prevalence studies at numerous hospitals, I found many pressure ulcers that are missed or with improper documentation. I found that often fungal rashes, healed pressure ulcers, blanchable redness, and moisture related maceration are staged as a pressure ulcer. One hospital that recently changed to computer charting, has a system that can list all patients that were documented with pressure ulcers on a given day. What we found useful for the wound care nurse to do, was monthly pull up a list of all pressure ulcers that were documented and validate them. While doing this educating the staff nurse. After doing this for several months, when the quarterly prevalence was performed, there was markable improvement in documentation.

Original Post
September 7, 2009
Title: Documentation on Bedsores, comment

Having worked in the NICU for many years, we see several issues with skin breakdown. For the micro-preemies who are lacking the epidermis (or extremely thin epidermis)- it is especially hard to not have skin breakdown, anything that potentially touches their skin will cause breakdown. All of these babies are considered critically ill therefore require several EKG leads, pulse oximetry probes and other transcutaneous monitors. These monitors should be repositioned every couple of hours to minimize the damage and burns. Documenting and notifying the physician of skin breakdown is EXTREMELY important with these patients as they are at such high risk for infections.

Original Post
August 20, 2009
Title: Documentation of Bedsores, comment

This is very true about the documentation of bed sores being incorrect. In the ICU where I work at, we actually document initially if there are any sores as soon as the patient arrives. It is located in the admission assessment. After that it is up to the nurses top document if there have been any changes in the skin integrity of the patient. Multiple time we see a skin assessment documented with a stage one/two pressure ulcer when reality is that it is incontinence associated dermatitis. Most time the IAD can resolved by either timely cleansing of the person, the insertion of a rectal tube and foley catheter (if not previously present) and some type of barrier ointment. In a way prevention is the best medicine for IAD and Pressure Ulcers, in companied with good core and forensic assessment skills. If the pt is having large loose stools, create a prevention to keep the skin intact.

Original Post
August 3, 2009
Title: Documentation of Bedsores, comment

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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