Pressure Ulcer Assessment and Documentation

Accurate assessment and documentation of skin is an important nursing activity yet the task of identifying and documenting wounds can be difficult. New regulations from the Centers for Medicare and Medicaid dictate that hospitals will not receive payment for the treatment of stage III or stage IV hospital-acquired pressure ulcers. Literature supports that accurate assessment and documentation of a pressure ulcer is important to the care of the patient, to provide legal documentation, and for reimbursement. The purpose of this project was to develop and implement a pressure ulcer assessment and documentation pocket guide. The development of the pocket guide was guided by Malcolm Knowles’ adult learning theory and developed by evaluating different pocket guides, the NPUAP website, and evidence based literature. The project employed an intervention, post intervention evaluation design. The sample was drawn from nurse members of the Pressure Ulcer Prevalence Committee at the Miriam Hospital in Providence, RI. Nurse members of the committee who agreed to participate utilized the Pressure Ulcer Assessment and Documentation Pocket Guide to assess patients during the monthly meeting and then completed an evaluation. The guide was evaluated as being valuable in assessing and documenting pressure ulcers and it was recommended for distribution to staff nurses. Use of the tool has the potential to improve assessment, identification, and documentation of pressure ulcers. Implications for advanced practice are discussed.