Jessica Listman-Ward

NURS 404-701
Frostburg State University
May 2, 2014

 Documentation

is key to protecting
healthcare industry
All new admissions need thorough assessment
and documentation
Do not miss any skin breakdown, ulcers,
wounds, etc.
Place wound consult if necessary

 Do

not skip any part of the admission process

Do not be the reason that JACHO dings the
hospital
If patient arrives with wound-measure and
document it at the time of assessment
Ensure that all staff does frequent rounding
and turn patient if necessary
DO THE RIGHT THING, DO NOT WAIT

 So

now that we know that documentation is

important, how do we ensure that every
nurse does it every time?
We need to create a way for computer
systems to lock up and flag skin
assessment
Prevents nurse from skipping this crucial
piece of documentation

 The

diagram on the previous slide shows an

example of not documenting a skin/wound
assessment on admission
This slip up costs the hospital money
Hospital becomes liable for existing and new
wounds
Patient goes without treatment for wounds
until someone documents them
Cost of single pressure ulcer can be up to
$70,000 (Lynch, 2010, p. 61)
In the US approximately $11 billion/year goes
into wound care (Lynch, 2010, p. 61)
6

Month 1: Send out

notice to inform
nurses of an
upcoming change
in system, Have IT
create the
change, Look at
which units
consistently lack
documentation

Month 2: Begin
training all staff
on the
documentation
changes

Month 3:
Implement the
change on units
that have
consistently
lacked
documentation

Month 4: Get
feedback from
units

Month 5:
Introduce the
change hospital
wide

 Lewins

theory describes this change

1. Unfreezing- Motivation to change
occurs, aware of the problem
2. Moving- Change is planned and
started, information gathered
3. Refreezing- Changes are integrated
and stabilized
(Blais & Hayes, 2011, p. 257-58)

 Do

the right thing every time

Be thorough with your assessment
Proper documentation can help the unit, the
hospital, and most importantly the patient
Work with the team- MD, wound nurse, etc.
to provide quality care to the patient
Dont cut corners-always check the patient
for wounds/ulcers
Follow preventative protocol
When in doubt put in consult with wound
nurse
10

11

AHRQ. (2011). Skin Assessments Conducted as

Part of Patent Intake Improve Documentation of
Pressure Ulcers on Admission, Reduce Incidence
During Stay. AHRQ Innovations Exchange.
Retrieved from
http://www.innovations.ahrq.gov/content.aspx?i
d=3221

Blais,

K.K. & Hayes, J.S. (2011). Professional

Nursing Practice. Upper Saddle River, NJ:
Pearson.
Lynch, S. (2010). Steps to reducing hospital
acquired pressure ulcers. Nursing, 40(11),
61-62
12