Skin assessment


Hello I'm new to the site. I have been a nurse for 5 years. Recently I started a new job at an Alf. We have gotten a new administrator and she is changing everything which most tend to do. She has been on my ass from the get go. On Saturday my day off she called me and told me that she had a question on my skin assessments. She said that I had no new areas noted. I agreed. She stated well patient A has a rash. I agreeded and told her that it was documented on the previous assessment that was done earlier in the week. She then stated that everytime we are to do a skin assessment we need to put everything on it even if it was previously. documented. So if they have a scar on them that has been there for 25 years it needs to be documented everytime not only on admission. Every place I have worked had me doing it the way I am. How do you do your skin assessments? Also when there is an area noted we chart on it for 3 days and what intervensions we did.

Specializes in SICU, trauma, neuro. Has 16 years experience.

When I worked in a SNF, we documented every anomaly every time. Think of it this way--Nurse A is documenting a pressure ulcer that the resident has had for weeks. Nurse B only documents the new skin tear; the pressure ulcer is not new w/ this assessment. Nurse B does the skin check a few weeks in a row and continues only documenting new findings. Then one week, Nurse B is off on this resident's skin check day. Nurse A (or C, whatever) documents every abnormal finding, including this pressure ulcer that still hasn't healed. It's the same one that the resident has had for weeks, but according to the documentation it looks like a new pressure ulcer. That's a ding for the facility and could have reimbursement implications.