Documentation and record-keeping in pressure ulcer management

Edwin Chamanga, Renee Ward

    Research output: Contribution to journalArticlepeer-review

    Abstract

    National and international guidelines recommend the use of clinical assessments and interventions to prevent pressure-related skin damage. This includes the categorisation of pressure ulcers as avoidable or unavoidable, which is challenging in clinical practice, mainly because of poor documentation and record-keeping for care delivered. Documentation and record-keeping are influenced by the individual's employing organisation, maintenance procedures for documentation and record-keeping, and local auditing processes. A transfer sticker to enable patient assessment and promote pressure ulcer documentation was designed and implemented. The transfer sticker captures the date, time and location of a pressure ulcer preventive risk assessment and the plan of care to be implemented. The increased clarity of record of care achieved by using the transfer sticker has enabled the number of avoidable hospital-acquired pressure ulcers resulting from poor documentation on admission or ward transfers to be reduced. The transfer sticker helps staff identify patients at risk and allows interventions to be implemented in a timely manner.
    Original languageEnglish
    Pages (from-to)56-63
    JournalNursing Standard
    Volume29
    Issue number36
    DOIs
    Publication statusPublished - 6 May 2015

    Keywords

    • avoidable pressure ulcers
    • documentation
    • pressure ulcers
    • record-keeping
    • tissue viability
    • unavoidable pressure ulcers
    • documentation ÔÇö standards
    • nursing assessment ÔÇö methods
    • pressure ulcer ÔÇö classification
    • pressure ulcer ÔÇö therapy
    • Nursing and midwifery

    Fingerprint

    Dive into the research topics of 'Documentation and record-keeping in pressure ulcer management'. Together they form a unique fingerprint.

    Cite this