November 6, 2012—Documentation of Existing Pressure Ulcers
As of November 6th, all patients admitted to MGH must have a pressure ulcer assessment documented in POE by an MD, NP, PA, or CNM. This documentation fulfills important quality improvement and regulatory requirements. If an existing pressure ulcer is not documented within 24 hours of admission, it is assessed to be the result of suboptimal care during the current visit. Pressure ulcers that are present when the patient is admitted must be noted, not only so the patient receives the appropriate treatment, but also to ensure that MGH receives compensation for that treatment.
Clinical nurse specialists and RNs involved with the patient’s care may be able to provide pressure ulcer information. On identifying a pressure ulcer, consult the clinical nurse specialist who is the unit-based wound specialist, for assistance with planning and staging treatment.
Key features:
A new Screening order is available from templates and the General Care order group, for providers to document the result of the pressure ulcer assessment
Until the pressure ulcer documentation is completed, ordering providers are prompted to document whether a pressure ulcer is present at 6, 12, and 18 hours after admission
If the patient’s pressure ulcer status is not available, there is an option to defer the documentation; however, it cannot be deferred after 18 hours
On documenting that a pressure ulcer is present, providers are prompted to order a consult if needed
For patients with a documented pressure ulcer, orders for wound care are followed by a prompt to select optional associated orders related to chemical and sharp debridement, which may be used to help with wound healing.
Instructions:
See also: