Improving Skin Assessment Documentation in the Electronic Health Record to Prevent Perioperative Pressure Injuries

Area of Science:

• Healthcare informatics
• Nursing practice
• Patient safety

Background:

• Pressure injuries pose a significant challenge in healthcare settings.
• Effective communication of skin assessments is crucial for pressure injury prevention.
• Existing electronic health record (EHR) systems may have documentation gaps hindering consistent care.

Purpose of the Study:

• To enhance pressure injury prevention processes within a pediatric trauma hospital.
• To address critical gaps in EHR documentation for skin assessments and pressure injury information.
• To improve inter-service communication regarding patient skin integrity.

Main Methods:

• A workgroup comprising wound care, nursing informatics, and perioperative specialists was formed.
• A change management framework guided the examination of existing processes.
• Evidence-based guidelines were used to develop and implement updated EHR documentation fields.

Main Results:

• A critical gap in EHR documentation features was identified, impeding consistent communication.
• Updated, standardized documentation fields were successfully implemented across the EHR.
• Postimplementation surveys indicated high levels of nurse satisfaction with the changes.

Conclusions:

• Standardizing EHR documentation significantly improves nurses' ability to communicate skin assessment data.
• Enhanced communication through improved EHR functionality supports effective pressure injury prevention.
• The implemented changes maintained a low rate of surgically acquired pressure injuries.