Documentation and record-keeping in pressure ulcer management
Intended for healthcare professionals
Art & Science Previous     Next

Documentation and record-keeping in pressure ulcer management

Edwin Chamanga Service lead, Tissue viability, Ipswich Hospital NHS Trust, Ipswich, England
Renee Ward Manager, Woodbridge ward, Ipswich Hospital NHS Trust, Ipswich, England

National and international guidelines recommend the use of clinical assessments and interventions to prevent pressure-related skin damage. This includes the categorisation of pressure ulcers as avoidable or unavoidable, which is challenging in clinical practice, mainly because of poor documentation and record-keeping for care delivered. Documentation and record-keeping are influenced by the individual’s employing organisation, maintenance procedures for documentation and record-keeping, and local auditing processes. A transfer sticker to enable patient assessment and promote pressure ulcer documentation was designed and implemented. The transfer sticker captures the date, time and location of a pressure ulcer preventive risk assessment and the plan of care to be implemented. The increased clarity of record of care achieved by using the transfer sticker has enabled the number of avoidable hospital-acquired pressure ulcers resulting from poor documentation on admission or ward transfers to be reduced. The transfer sticker helps staff identify patients at risk and allows interventions to be implemented in a timely manner.

Nursing Standard. 29, 36, 56-63. doi: 10.7748/ns.29.36.56.e9674

Correspondence

edwin.chamanga@HRCH.NHS.UK

Peer review

This article has been subject to double blind peer review

Received: 12 October 2014

Accepted: 20 February 2015

Want to read more?

RCNi-Plus
Already have access? Log in

or

3-month trial offer for £5.25/month

Subscribe today and save 50% on your first three months
RCNi Plus users have full access to the following benefits:
  • Unlimited access to all 10 RCNi Journals
  • RCNi Learning featuring over 175 modules to easily earn CPD time
  • NMC-compliant RCNi Revalidation Portfolio to stay on track with your progress
  • Personalised newsletters tailored to your interests
  • A customisable dashboard with over 200 topics
Subscribe

Alternatively, you can purchase access to this article for the next seven days. Buy now


Are you a student? Our student subscription has content especially for you.
Find out more