The Attorney's Quick Guide: "The 6 Essential Elements of Pressure Ulcers You Must Find in the Medical Record."
The contents of the medical record, such as deviations from standards of care, inaccurate or incomplete documentation can make the difference in your pressure ulcer case.
According to JCAHO (Joint Commission on Accreditation of Healthcare Organizations), the medical record should "reflect timely and proper medical and nursing intervention and treatment based on medical diagnoses."
This article covers what every attorney in pressure ulcer litigation must find in the medical record of the acute and long-term care settings, including:
• The six elements of a pressure ulcer assessment that must be documented by the nurse.
• The seven common areas for pressure ulcers to develop.
• A common documenting gap that kills the defense.
• 4 Questions that must be asked about infected wounds.
• What is eschar and how it can delay pressure ulcer healing.
Acute-Care vs. Long-Term Care
Nurses are educated to assess and evaluate skin integrity. It is standard practice for skin assessments to be done with patient assessment on a regular basis. Whether in the acute or long-term care setting, skin assessments are an important part of planning, interventions, and evaluation of treatments. According to the recommendations of the Agency for Health Research & Quality (AHRQ), assessments for skin breakdown development should be done upon admission to the facility, then periodically as follows:
• In the acute-care setting; every 24-48 hours.
• In the long-term care setting; weekly for the first four weeks, then monthly or quarterly.
In most cases, pressure ulcers can be prevented. When they are present; complications can develop such as infections and prolonged hospital-stays. The patient's overall prognosis decreases and it may contribute to premature mortality. This is why healthcare professionals must thoroughly document pressure ulcer assessments. Assessment forms and flow sheets will vary from facility to facility, but the information collected does not. Use the information below as a guide for pressure ulcer cases.
Location of the Pressure Ulcer (P.U.)
• The seven common areas in the body for pressure ulcers to develop are: buttocks, sacrum, heels, elbows, inner knees, back of the head and ears.
Measurements of the Pressure Ulcer
• Measurements should be documented in centimeters and dated. (2.54cm equals 1 inch)
• Documentation with measurements in inches or related to objects for comparison such as a nickel
or grapefruit is unprofessional and is not acceptable.
• Depth of the P.U. must be documented, otherwise the documentation is incomplete.
NOTE: The depth measurement is a common documenting gap. Most nurses overlook the depth
of the wound and these measurements are frequently missing in the medical record.
Presence of Infection
• Nurses are expected to document signs of an infected pressure ulcer.
• Infected wounds are painful! Did the nurse provide pain relief during wound care?
• Documentation should include: color, purulent drainage, and foul odor.
• If an infection is present, is it systemic or local? What interventions were implemented to treat the infection?
• Did the patient receive intravenous antibiotics? Topical antibiotics?
• Did the nurse document signs of wound healing?
NOTE: The Agency for Healthcare Policy and Research (AHCPR) states that a wound must be cultured with a tissue biopsy if the pressure ulcer does not demonstrate signs of healing with topical antibiotics within a two week period.
• Assessement of the surrounding skin can identify if an infection is present or is spreading.
• The nurse must note skin color, temperature, and any discoloration including areas of erythema.
Margins of the Pressure Ulcer
• Smooth margins indicate normal healing.
• Rolled margins indicate the wound is old and probably chronic. These types of edges are healed and may require surgical intervention.
Wound Bed (pressure ulcer bed)
• The color of the wound bed is the best indicator of healing. The color, amount of wetness and granulation are the best indicators for pressure ulcer healing progression.
• Is the wound moist or dry? This information is a key factor in selecting the correct dressing that will support healing.
• Is there documentation noting granulation tissue present?
• Is eschar present? If so, what measurements were implemented to prevent further skin breakdown and wound healing delay?
• Eschar is dead tissue containing non-viable cells and debris that promote bacterial growth. Eschar can also decrease circulation and cause infection.
• Dead tissue in the pressure ulcer will delay healing by preventing growth of healthy tissue. Healthy new tissue cannot grow over dead tissue.
• Is granulation tissue present?
NOTE: Granulation will not happen as long as eschar is present.
Systemic conditions must be considered in relation to wound healing. Many conditions such as renal disease, anemia, sepsis, malnutrition, and diabetes can delay or alter wound healing.
The medical record may reveal poor documentation, which may be equal to a poor assessment. A poor assessment prevents proper planning, interventions, and treatments of a pressure ulcer. A nurse or doctor's poor documentation can lead to a cascade of incomplete information that is passed on from healthcare professional to another, which may result in an overall poor prognosis. Using authoritative sources and experts to quickly find the answers to your pressure ulcer questions will save you time and can make the winning difference.
Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.