I am a med/surg RN who is trying to figure out how to improve our wound documentation on admissions and during hospital stay. I am trying to find information on how other hospitals handle their admission/discharges and wound care. During admission assessments there are about 75% of the nurses that don't visually do an assessment. They ask the pts "do you have any skin issues like bruising, rashes, sores, cuts, etc. that I need to know about?" Obviously if a pt. states "no" but two days later is found to have a Stage II pressure ulcer on his coccyx the hospital is now liable for that ulcer.
Currently we have 3 RNs that split a 24 bed floor in half. They each have 1-2 LPNs with occasional SNT/CNAs. If we are lucky we have a fourth RN who charges but mostly one of the three RNs charge. The RNs responsibilities are notes on patients or passing meds and taking orders off. We have a GREAT deal of new grads so very little experience.
We know the reasons as to why they are not always a FULL assessment (staff shortage, lack of time, inexperience, etc). I realize it is crucial to do a FULL assessment but meeting some resistance from other nurses. If I come up with a better solution that WORKS at other facilities then maybe I can change their views. It is either we decide or management will. ANY help would be EXTREMELY helpful! Thanks
Our wound expert says photographs are not reliable. Unless you have exact distance, angle, and lighting it won't look the same if taken twice within a minute.
Also- quite honestly....wound or not- if you came at my bottom with a camera- I'd be sueing for something- and I'm an intelligent alert individual. I think the practice of taking pics is horrible and demeaning.
What is truely horrible is that people get stage 4 decubs to begin with. If patients are being admitted to the hospital with a stage 4 decub, as the saying goes, a picture is worth a thousand words. If medicare is not going to pay for stays with decubs developing, we better have some way to accurately document that decub on admission.
rita359
437 Posts
What is truely horrible is that people get stage 4 decubs to begin with. If patients are being admitted to the hospital with a stage 4 decub, as the saying goes, a picture is worth a thousand words. If medicare is not going to pay for stays with decubs developing, we better have some way to accurately document that decub on admission.