Skin Assessment Question

[annie.rn]

We chart in Meditech at the hospital where I work. For each body system in the physical assessment you place a "Y" (for "yes") or an "N" ( for "no") next to the question that says "WDP?" ("Within Defined Parameters").

My confusion is this: I find people will chart "no" under "integumentary WDP?" and "no" under "skin intact?" if a patient has a tattoo or scar. They will then document each scar and each tattoo in the area where one would document incisions, rashes, wounds, etc.

I can see charting "no" under the more general "integumentary WDP?" because having a scar or tattoo is not something a body is born with and therefore makes a person's skin technically not WDP.

However, charting "N" under "skin intact?" for a tattoo/scar doesn't make sense to me because their skin is not broken down.

So, do you chart tattoos/old scars?

If so, based on what I've described, where would you chart it?

I've asked a few people at work but, as with most things, you get a different answer depending who you ask.

Thanks!

[loriangel14, RN]

I never chart tattoos or scars.I may chart a scar if it extreme when I am doing an admission but not in every day charting.

[blackvans1234]

I think our system asks something like ''skin intact'' yes or no.

[JBudd, MSN]

Our charting allows for a comment to be attached, I would describe any anomalies there (not really necessary to chart the tats every time, just on the initial overall assessment).

[psu_213, BSN, RN]

Coming to it from an ED perspective...all of our assessments are focused--not necessarily every square inch of the body. I cannot see any reason to charts the specifics of a tattoo (in the PMH section of our charting, there is a check box for "tattoos/piercings"--mostly for MRI purposes I believe). I don't see any reason to chart "red rose on right hip and 'mother' inside a heart on left deltoid."

Scars I will chart if pertinent to the pt's CC. For instance, if he/she comes in with knee pain and they have a knee surgery scar I would chart something brief on it, like "healed surgical scar on right knee."

[Nurse Kyles, BSN, RN]

We use meditech, but it sounds like ours is configured a little differently. The only time I chart tattoos is in the Pre-operative intervention that specifically asks if the patient has tattoos.

[Here.I.Stand, BSN, RN]

We don't chart ink or old scars either. The only scars that get mention are if the pt is in long enough for a surgical incision to heal, we chart it as wound type: incision, appearance: healed.

[anon456, BSN, RN]

I see other nurses do this, too, and I don't. I will chart that all skin in intact except xyz wounds or rashes that are present (if any). I do make notes on "multiple healed scars present on abdomen" or "mongolian spot present on sacral area," for example. The mongolian spot is especially important as an oncoming nurse who has never seen it might think it's a bruise. The multiple healed scars may be important to indicate that the patient has a complex medical history and the skin in that area is not as flexible and perhaps more prone to breakdown. But it's not entirely necessary to chart on healed scars.

I also get bothered when someone charts on a wound that is covered by a bandage. You can't see the wound under the bandage, so you can't tell if it's well approximated or whatever. All you can chart is "unable to visualize wound, covered by dressing. Small amount of dried drainage present on dressing."

[CWONgal]

As a wound care nurse, I never chart anything about tattoos. I suppose I would if the person developed cellulitis as a consequence of a tattoo but it's not ordinarily the focus of the skin assessment. I have charted on scars because as was mentioned previously, we often see them r/t surgeries. You will also see scars from healed pressure ulcers. As Anon said it is important to document healed scars and discolorations of the tissue. I will say however unless you've been directed to not remove a dressing you should always do so w/ your assessment. I have had many MANY nurses tell me they didn't look at the wound because there was a dressing in place. I've heard this too w/ the foam dressings used on the sacrum. How else are you going to know what is going on with the wound if you can't see it?

[loriangel14, RN]

We have some types of dressings that are intended to be left in place for several days. Our charting has an option for checling off "dressing is dry and intact".

[annie.rn]

Thanks, everyone. I have never charted tattoos either (unless specifically asked for) but see other nurses do it pretty regularly where I work so I was interested to know what other people do. I'll keep charting skin assessments the way I always have.