Documentation and record-keeping in pressure ulcer management.

Area of Science:

• Nursing
• Patient Safety
• Healthcare Management

Background:

• National and international guidelines emphasize clinical assessments and interventions to prevent pressure-related skin damage.
• Categorizing pressure ulcers as avoidable or unavoidable is clinically challenging due to poor documentation and record-keeping.
• Organizational factors, documentation maintenance, and auditing processes significantly influence record-keeping quality.

Purpose of the Study:

• To design and implement a transfer sticker to improve patient assessment and pressure ulcer documentation.
• To enhance the clarity of care records for pressure ulcer prevention.
• To reduce the incidence of avoidable hospital-acquired pressure ulcers linked to documentation deficiencies.

Main Methods:

• A transfer sticker was developed to capture essential details of pressure ulcer risk assessments and care plans.
• The sticker was implemented to facilitate patient assessment and promote consistent documentation during transfers and on admission.
• The impact of the sticker on documentation clarity and pressure ulcer incidence was evaluated.

Main Results:

• The transfer sticker increased the clarity of recorded patient care related to pressure ulcer prevention.
• A reduction in avoidable hospital-acquired pressure ulcers was observed, particularly those stemming from poor admission or transfer documentation.
• Staff were better equipped to identify at-risk patients and implement timely interventions.

Conclusions:

• The transfer sticker is an effective tool for improving pressure ulcer documentation and patient safety.
• Enhanced record-keeping through the transfer sticker contributes to a decrease in avoidable pressure ulcers.
• Timely identification of at-risk patients and prompt intervention are facilitated by the sticker.