Nurses' documentation about pressure ulcers

Documentation in a patient's medical record is a nurse's legal and professional responsibility. Descriptive charting about pressure ulcers is critical since it may affect treatment modalities. The purpose of this research was to examine what nurses chart about pressure ulcers. The IAET Standards of Care Dermal Wounds: Pressure Ulcers (1987) was used as a guide. Nursing notes from 167 medical records were examined. None of the nurses' notations contained 100 percent of the items examined in this study. The most frequently occurring descriptor was location (74.2%). This research documents deficiencies in nurses' charting about pressure ulcers.