Published Sep 4, 2003
Recent survey dinged us on edema measurement. Our current policy states to use measurements of 1+, 2+, 3+, 4+ -- if no pitting we measure in cm. Surveyors say that if they see 1+ measurement and the next visit we measure that this is inconsistent. So how do we jump through that hoop?
Any suggestions would be appreciated.
I'd document in the soap note exactly what you see in addition to the "check off" boxes (if that's what you use on your care plan).
For instance. "L Ankle girth 22 cm with 2+ pitting edema to mid calf; R ankle girth 23 cm with 2+ pitting edema to just below knee". Be sure you document though what you DID about that assessment, if anything. If this is a change for the patient you can document that you verified that patient is taking diuretic as prescribed and reviewed no-salt diet...etc, etc. Or that you made a call to the physician and received an order for whatever.
I KNOW it is a pain but in reality, you probably are assessing those things and developing an intervention so take credit for by documenting it! It also helps to CYA!
renerian, BSN, RN
I measure to be able to document changes better. renerian
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