Documentation: Complicated Pressure Ulcers

by Joseph Li, MD

Introduction

This section contains 2 documents to assist providers in the care of patients with pressure ulcers. Providers are encouraged to utilize the Impaired Skin Integrity Documentation Form to describe the patient’s skin integrity and treatment plan. Please use a separate form for each site of impaired skin integrity. Providers are encouraged to utilize the Preventive Interventions to Maintain Skin Integrity Form to document the measures being undertaken to maintain the patient’s skin integrity. Although a given institution’s policy and procedures will dictate the answers to many of the questions below, this document serves to encourage you to think about the rationale behind these decisions.

Why document?

The answer to this question is applicable not only to the care of patients with pressure ulcers but to the care of those with any medical condition. Effective documentation allows clinicians the opportunity to provide high-quality care in an efficient manner. The basic principles of clinical documentation are no different when it comes to documentation of pressure ulcers. Documentation should be legible, complete, timely, accurate, concise, and readily available. Effective documentation allows the clinician to communicate with others his/her thoughts on when the pressure ulcer developed, the cause of the ulcer, whether it is improving or deteriorating, and interventions being taken to treat the ulcer. This information is important not only for patient care but may have an impact on reimbursement and serve as evidence for medical–legal action. This information may also be useful for quality improvement efforts.

Who should document?

Any provider involved in the care of the patient should be encouraged to document any changes in a patient’s skin integrity and any measures being taken to maintain a patient’s skin integrity. This may include a nurse, physician, nursing assistant, physical therapist, wound care specialist, or any number of health care providers. This being said, it should be the responsibility of one clinical provider to make sure that documentation occurs. This is usually the nurse’s responsibility, for several reasons. The nurse and his/her assistants spend the most amount of time with the patient throughout the day. This affords the nursing staff the greatest opportunity to observe any changes in the patient’s skin integrity. The nursing staff is also largely responsible for executing the in­ter­ven­tions to maintain a patient’s skin integrity. However, given this, physicians and other providers should be expected to contribute and not completely abdicate this responsibility to nurses only.

When should documentation occur?

At a minimum documentation should occur daily but should always occur when there is any change in or any intervention to preserve or treat a patient’s skin integrity. In a patient whose skin integrity is intact, documentation should occur daily. In a patient with impaired skin integrity, documentation would normally be expected throughout the day.

What should be documented?

• At a minimum, the following descriptive information should be documented regarding each pressure ulcer: site, type, size, color, exudates, odor, appearance of the skin around the wound.
• All interventions including, at a minimum, topic therapy and dressings should be documented.
• All efforts to maintain a patient’s skin integrity should be documented. This would include, at a minimum, efforts to reduce pressure, friction, shear, and moisture and efforts to maintain or enhance nutrition.

Where should documentation reside?

A given institution’s policies will dictate where a patient’s documentation will reside, but there are some guiding principles that may facilitate provider communication and patient care.

The goal is one consistent location.
Any and all clinical providers should be able to tell you immediately where the information regarding documentation of skin integrity resides in a given patient’s chart. Documentation that resides in multiple locations is often ineffectual and creates confusion. Decide on a single location in the chart and mandate all providers to adhere to placement of all documentation at this location.

Photographs are great but should not replace text
A picture is worth a thousand words, but it is the quality not the quantity of the words that matters. Photographs can be wonderful resources, particularly when a series of photographs is taken over time to demonstrate the change in a patient’s pressure ulcer. The biggest potential problem associated with the use of photographs to document pressure ulcers is that providers are tempted to use the photographs to replace other forms of documentation (e.g., people write less because of the falsely held belief that the photograph is sufficient in and of itself). This issue must be addressed if photographs are being utilized for documentation. The photographs themselves may not adequate describe a patient’s pressure ulcers (for example, there is no way to describe odor with a photograph). The use of images to document pressure ulcers is particularly a problem if institutions do not have an effective way to store or record the photographs. In an ideal situation, photographs would be recorded and stored digitally. Obviously, the value of photographs as documentation is limited by their quality and accessibility. There is no comparison between the quality of an instant photograph with that of a photograph from a more sophisticated camera. Photographs also are not much use if they are stored off-site in a warehouse after a patient’s discharge and cannot be easily accessed. Accessibility is often the most frequent problem when using photographs to document pressure ulcers.

Electronic documentation is great and often preferred, as long as it is easily accessible and does not impede documentation
The proliferation of electronic medical records (EMRs) has been a blessing and a problem when it comes to the documentation of pressure ulcers. It is wonderful to be able to open a patient’s chart on an electronic desktop anywhere inside or outside the hospital to view documentation from present or previous hospitalizations. The EMR often alleviates any accessibility concerns when it comes to viewing documentation, but the use of a computer interface to input data can create problems not seen with paper. It takes more time to log onto the computer and get to the appropriate screen. This issue may not be perceived the same by younger clinicians as by older clinicians, who may be less familiar or comfortable with technology. The nature of some of the documentation regarding pressure ulcers lends itself well to the use of templates. Those less comfortable with technology may find the use of electronic templates to be more cumbersome than paper templates. The use of a keyboard to enter data in and of itself may be a barrier that the use of pen and paper is not. The end result may be fewer words used to describe the patient’s pressure ulcer, which can result in lower-quality documentation.

Final words

Documentation is an essential element of any program to prevent pressure ulcers and to improve the care of patients with pressure ulcers. As you create the documentation process, do not expect instant success. Maximize the chance for success by seeking input from a broad-based coalition of providers. But also remember not to let perfection be the enemy of the good. Significant improvement will take time and will require continual monitoring of the system. Seek buy-in from reluctant providers by modeling ideal behavior and publicly rewarding those who participate.

Impaired Skin Integrity Documentation Form

Download the Impaired Skin Integrity Documentation Form

Preventive Interventions to Maintain Skin Integrity Form

Download the Preventive Interventions to Maintain Skin Integrity Form