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.e9674Correspondence
This article has been subject to double blind peer review
Received: 12 October 2014
Accepted: 20 February 2015