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NURSING DOCUMENTATION

OBJECTIVES 1. The learner will be able to state 2

components of documentation that meet the ‘Standard of Care’

2. The learner will be able to identify 4 characteristics of a ‘complete skin assessment’

3. The learner will be able to identify 4 characteristics of a ‘complete wound assessment’

DOCUMENTATION IS…

Ø Something you learn in nursing school Ø Something you do everyday at work Ø How you record patient vitals, diet, meds…

THE permanent record of nursing assessment and care provided…

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DOCUMENTATION

Ø ‘any written or electronically

generated information about a patient that describes the care or services provided to that patient’

SOME EXAMPLES…

‘Skin intact, red, and broken’ ‘The skin was moist and dry’ ‘Pulses are probably in both

feet’

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‘Examination of genitalia reveals that he is circus-sized’

‘300cc PWISOTF’ (Plus what I spilled on the floor)

‘Patient found dead: felt cold,

blanket added, voiced no

complaints’

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‘She has no rigors or shaking chills, but her husband states she was very hot in bed last night’

‘Large brown stool ambulating in the hall’

Documentation is the process of recording the patient assessment

and the care provided

It MUST demonstrate that the ‘Standard of Care’ has been met

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STANDARD OF CARE

What is it and who decides?

STANDARD OF CARE Ø Guidelines used to determine what a nurse

should or should not do Ø Model of established practice that is

commonly accepted as correct Ø Basis for nursing care that draws on the

latest scientific data from nursing literature Ø Based on the premise that the registered

nurse is responsible for and accountable to the individual patient for the quality of nursing care he or she receives

STANDARD OF CARE The nurse has a professional responsibility,

and is held accountable to document patient data that accurately reflects:

Ø Nursing assessment Ø Plan of care Ø Appropriate interventions Ø Evaluation of the patient’s condition Standard of Care

ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

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STANDARD OF CARE Developed and implemented to define the ‘quality

of care provided’

Ø Federal / State laws, rules and regulations Ø Professional organizations establish norms for

the average practitioner Ø The ANA and Joint Commission on Accreditation

of Healthcare Organizations (JCAHO) have established nationally recognized ‘Standards of Care’

POLICY AND PROCEDURE

In addition- Ø Nurses must understand and

follow the policies and procedural guidelines of their individual facilities

LEGAL CONSIDERATIONS The healthcare industry can be a minefield of

litigation when patients Ø Don’t heal as expected Ø Develop unexpected complications or

infections which can lead to prolonged recovery or even death

Lawsuits often involve all those who cared for the patient, including the nurse

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WOUND LITIGATION ON THE RISE

Ø Increasing elderly population Ø Regulatory climate Ø Misunderstanding by families as to the

cause of wounds Ø Perceived as ‘bad care’

Ø Public opinion that wound cases are an ‘easy target’

LEGAL CONSIDERATION

Ø Nursing documentation Ø often starting point in malpractice cases Ø can either deter a plaintiff from filing a lawsuit or

provide the leverage that is required to initiate one

Jurors and attorneys view what is written in

the patient record as the best evidence of what really occurred

PRESSURE ULCERS

The incidence of Hospital acquired pressure ulcers (HAPUs) is considered a ‘quality indicator’ of patient care

Ø ‘Quality care should not result in a HAPU’ Ø A ‘Never Event’ Ø High public awareness Ø Frequent involvement in litigation Ø Reimbursement issues

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The reality is that not all pressure ulcers are

preventable…. The nurse MUST be able to show that all

appropriate assessments and interventions were done….

…That the ‘Standard of Care’ was met

DOCUMENTATION THAT MEETS THE STANDARD OF CARE

Ø Timely Ø Accurate Ø Comprehensive Ø Complete

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

DOCUMENTATION THAT MEETS THE STANDARD OF CARE

ASSESSMENT, ASSESSMENT, ASSESSMENT…..

ü SKIN ASSESSMENT ü WOUND ASSESSMENT ü RISK ASSESSMENT

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

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SKIN ASSESSMENT

1.  TIMELY ü  ON ADMISSION ü  EVERY SHIFT OR VISIT ü  FOLLOW FACILITY POLICY

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

SKIN ASSESSMENT 2.  ACCURATE / COMPREHENSIVE /

COMPLETE ü  INTEGRITY- Alteration in Epidermis or Dermis ü  COLOR- Erythema, Pallor, Cyanosis… ü  TURGOR- Dehydration … ü  MOISTURE STATUS- ü  TEMPERATURE- ü  HIGH RISK AREAS-

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

SKIN ASSESSMENT

DOCUMENT AND REPORT ABNORMALITIES

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

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WOUND ASSESSMENT 1.  TIMELY

ü  ON ADMISSION ü  EVERY SHIFT OR VISIT ü  UPON TRANSFER / DISCHARGE ü  PER FACILITY POLICY

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

WOUND ASSESSMENT 2. ACCURATE / COMPREHENSIVE /

COMPLETE ü  Wound Type ü  Location ü  Measurement ü  Undermining / Tunneling ü  Wound Bed Appearance ü  Drainage ü  Odor ü  Surrounding Skin

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

WOUND DOCUMENTATION Paints the picture & tells the story

SURROUNDING SKIN

ODOR

DRAINAGE

APPEARANCE

UNDERMINING TUNNELING

MEASUREMENT

LOCATION

WOUND TYPE

WOUND

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

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WOUND TYPE FOR PRESSURE ULCERS: Ø If you know how to stage it-Do it! Ø If you are uncertain-Describe it!

SACRAL AREA

COCCYX

TROCHANTER ILIAC CREST

GLUTEAL FOLD ISCHUIM

LOCATION, LOCATION

Correctly identify wound location

Sacrum Coccyx

MEASUREMENT

LENGTH X WIDTH X DEPTH

Longest point Head to toe direction

90 degree angle Deepest point

Perpendicular to length Widest point

Document on Admission and per facility policy

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UNDERMINING / TUNNELING

UNDERMINING TUNNELING

Document with measurement

APPEARANCE

GRANULATION TISSUE SLOUGH ESCHAR

Document tissue type or describe color

DRAINAGE

How much and what does it look like?

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ODOR

Document presence of…

SURROUNDING SKIN

Document condition of skin surrounding wound

REALITY

Audits are enlightening… Ø Wrong location Ø Wrong wound type Ø Wrong pressure ulcer stage

Ø Ever changing pressure ulcer stage… Ø Missing assessment data Ø Inconsistencies from shift to shift

and day to day

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Common Liability Issues

ü Lack of documentation ü No admission assessment ü Discrepancy with prior / post facility

assessment / staging ü No measurements ü Lack of interventions

ü Specialty support surface ü Off-loading ü Documentation of turning / repositioning

MORE Liability Issues

ü Failure to identify skin breakdown ü Failure to notify doctor of changes in wound ü Failure to apply proper treatment ü Failure to obtain wound care consult ü INCONSISTENCY IN DOCUMENTATION

AUDIT EXAMPLE Date 2/28 2/

28 2/ 29

2/ 29

3/1 3/ 1

3/2 3/2 3/3 3/3 3/4 3/4 3/ 5

3/5 3/6 3/6 3/7 3/7 Wound Consult

Time 10Am Pm Am Pm AM Pm Am Pm Am PM Am Pm Am Pm Am PM Am Pm AM PU Stage III III III III SDTI I III II Un-

stageable Measure 4X2 4x2 4x2 3 x 1.2 x .2 Undermining Tunneling Wound color Pink yellow White /

yellow White / yellow

Red / yellow

Pink / yellow

Pink / yellow

Green Pink UTA UTA White / yellow

Incis edges approx separated Separated Separated Separated NA UTA UTA NA Exudate amt Small None None None None None UTA UTA Small Exudate type Serous None None None None None UTA UTA Serous Odor Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent Surrounding skin Intact Intact Intact Intact Intact Intact Intact Intact UTA UTA Intact Closure None None None None None None Liquid

tissue None None None None NA

Dressing assess/changed

Changed Changed Changed Changed WDP Changed No Change

WDP WDP Changed

Wnd cleanser NS NS NS NS NS NS Dressing applied Gauze Gauze Hydrogel

Gauze Hydrogel

Foam Gauze Hydrogel

Foam Hydro-

gel Hydro- colloid

Hydrocolloid Hydrogel Foam

Foam Hydrocolloid

Secondary dressing

None None other None Foam None Other

Secured with Paper tape

Paper tape

Paper tape Paper tape

Paper tape

Paper tape

Good News: Wound is noted on admission Not So Good News: No Charting: for the next 3 days Staging: Inconsistent (IIIàSDTIàIàIIIàII)-actually Unstageable Measurement: noted on day 3 / Stage III, no depth documented, ever Incision edges: Documented consistently… (in a pressure ulcer?) Closure: ‘liquid tissue’ ? Dressing: Not assessed consistently-dressing type changes shift to shift

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DOCUMENTATION TIPS

Documentation should include: Ø Data from Nursing Assessment Ø Nursing actions / interventions taken Ø Individuals notified about concerns / issues Ø Evaluation of actions

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

DOCUMENTATION TIPS Ø Document within timeframe outlined per

facility policy Ø Correctly identify LEFT and RIGHT Ø Correctly identify LOCATION, especially

Ø SACRAL Ø COCCYX

Ø Correctly stage all PRESSURE ULCERS Ø Do NOT stage wounds that are

NOT pressure ulcers Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

GENERAL CAUTION Spell correctly: Ø “Fecal heart tones heard” Use appropriate words and grammar: Ø “The pelvic exam was done on the floor” Avoid inappropriate comments: Ø “Patient received insufficient care today

because nurse patient ratio was 1:7”

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Don’t Forget RISK ASSESSMENT

ü  Evidenced based tool: Braden / Norton ü  Follow facility policy for frequency ü  INTERPRET RESULTS

ü Implement appropriate interventions ü Use score to adjust the plan of care

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

IMPROVING COMPLIANCE

Ø Staff education and support related to

wound ID, pressure ulcer staging, wound assessment..

Ø Tools and visuals to assist staff in wound identification and staging

WOUND DOCUMENTATION

FORMAT SUGGESTIONS Ø Nurse ‘friendly’ Ø Contain all components necessary for ‘complete’ documentation Ø Improves probability of comprehensive doc

Ø Visual

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EXAMPLE 1-INDICATE LOCATION OF WOUND (S) ON BODY DIAGRAM 2-DOCUMENTATION FOR: ALL WOUNDS EXCEPT INTACT SURGICAL WOUNDS

Wound #

Location Wound Type / Pressure Ulcer Stage

Wound Measurement

Appearance Drainage Odor Cleansed with

Dressing Applied

Click boxes for ‘smart

text’ options

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Left ILIAC

PRESSURE ULCER STAGE

II 2 X 2 X .2cm RED SCANT

SEROUS ABSENT NS Hydrocolloid

3-DOCUMENTATION FOR INTACT SURGICAL WOUNDS ONLY A-Intact surgical incisions #___ through #___ (choose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) B-Incision Appearance __________________________ (choose smart textà (clean / dry / well approximated / without erythema / without drainage / without odor) C-Closure ______________ (choose smart textà staple / sutures / glue / other / none)

‘SMART TEXT’ OPTIONS Wound# àchoose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) Location àchoose smart textà (coccyx, ischial, scaral…) Wound Type / àchoose smart textà (arterial, diabetic, PU stage I, PU stage II, PU stage III…) Measurement àchoose smart textà (length 1 / 2 / 3…) (Width 1 / 2 / 3…) (Depth 1 / 2 / 3...) Appearance àchoose smart textà (red / pink / yellow / gray….) Drainage àchoose smart textà (none, scant, small…) Odor àchoose smart textà (absent, present) Cleansed with àchoose smart textà (NS, wound cleanser...) Dressing àchoose smart textà (Calcium alginate, gauze, hydrocolloid…)

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BOTTOM LINE

Every nurse is responsible for the patient care provided and the DOCUMENTATION

to support it

SOME OPTIONS…

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NURSING TOOLS

Ø Nurse ‘cheat sheet’ Ø Pressure ulcer staging analogy Ø PU staging algorithm Ø Musical wound assessment

‘Cheat Sheet’ for Nurses

Pressure Ulcer Analogy

Baker Pressure Ulcer Staging Tool

Nursing Tools

Musical Wound Assessment

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

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Thank You

Wound Care Nursing