Skin tear narrative note

clockwood · Oct 1, 2015

Very good what you have. I believe it is ok to write "per standing order" or "per protocol" ...that's what I do anyway. It's always hard working by yourself bc you can't bounce ideas off of other people, like, "should we notify family, doctor?", etc. For any injury that happens for an unknown reason, I always like to include the patient's mental status. So I will say something to the effect of "Patient is calm and oriented. Pt rates pain 0/10. No distress at this time." Or- "Patient has gotten out of bed four times in the past hour to go to the bathroom. States, 'I just can't get comfortable.' Appears mildly agitated and restless." Just to give reader an idea... :) You hit the high points though: when you noticed tear, when resident noticed tear (he didn't recall), how you addressed it, pain, signs of infection.

amoLucia · Oct 5, 2015

Word of advice (from a long time LTC nurse) - I, MYSELF, make the family phone call just before I leave in the morning. I've been burnt when this type of non-critical phone call got omitted unintentionally. Also, it saves any problem if family visit before the phone call is made. Nothing worse than family being taken by surprise when they see a new bandage on Mom Mom's shin or Pop Pop's elbow.

I don't want family to think we are trying to hide anything and it gives them the opportunity to hear the news directly FROM ME, not second hand from a secretary.

Make sure you do an incident report, usually required by most facilities' P&P. Write your MD order for wound care on your order sheet, on your TAR record, your 24 hr desk report sheet, and care plan, if nec.

Your script is pretty decent and could also be adjusted for any bruises noted. Always report any new bruising - if you don't the next guy behind you will and your shift may be suspected of causing the bruising. Don't assume that someone else reported a newly evolving bruise unless you see it documented in the nurses notes. And you go thru all the same steps. Again, you don't want family being the first to see some big nasty ecchymosis. Otherwise, family will be in the DON's office or calling the Ombudsman/DOH/APS.

Similarly, I leave a message with the MD's service as well.

Be very careful if there's any chance of a head injury with any head bruises or skin tears. Start neuro checks and check for any coag studies if needed. Let MD know.

And with bruises/skin tears, think simple ROM/ADL skills. Maybe a fracture involved? It can take up to 48 hours for fractures to be really painful or debilitating and seniors have diminished capacity for pain sensation and altered physical capabilities. And then if there's dementia ...

You want your care to reflect that you were thorough when you provided good care for the pt.

SLS_RN · Dec 10, 2015

I don't know what policies are in your state, in my area for any and all injuries that are of unknown origin has to be reported to department of health...documenting in the narrative "injury of unknown origin" is always a no no. May be something for you to check into. Check with your DON. Also instead of writing up a narrative, maybe it would be a better idea to make a list of all the things you need to be assessing for and including with the documentation of a skin tear. If you have a narrative already prepared it is possible that maybe you would overlook some details. For example almost like a check list, even write it up as such and make notes on the paper with size, drainage, etc as you assess the area. Also good idea to put on there your notifications. As someone earlier mentioned I would call at the end of my shift.. That way you know for a fact it is done. I have also had family members come in first thing and be upset that they were not notified of an injury, regardless of how small or minor. They will appreciate the communication. How this is helpful.