Ulcers - Decubitus only: Difference between revisions

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**HSC B3- Pat is finding that there is poor documentation on charts about when and decubitus ulcer present on admission or when acquired after coming to a ward. (exception, HSC_D5 is excellent with documentation. Stage of ulcer is rarely documented in the chart. Pat looks at the nursing FLOW SHEET for indication of some sort of a dressing change that would clue her in that there may be a bed sore. Pat will then track down a bedside nurse to find out what dressing is for and if bedsore what would be the stage. Most time it is a guess because of poor documentation by both Doc and Nurse.[[User: PStein | PStein]]

*** For critical care we can only put in 9 complications and bedsores is just not a top priority. If this is important to capture then we would need to add it to our tmp file. If the nurses don't chart skin breakdown there is no way to tell if it was there. We can only use what is written down as sometimes we are looking at charts after the patient is discharged. Documentation can be poor for this sometimes, I agree. --[[User:LKolesar|LKolesar]] 12:55, 3 May 2010 (CDT)

****At the Vic we have skin and wound asessment/intervention sheets that we check to see if pts have any problems also we check Patient care flow sheet to see if anything has been documented and also as above if we use up 9 complications this problem gets omitted also lack of nursing staff on the wards equals lack of documentation

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 **HSC B3- Pat is finding that there is poor documentation on charts about when and decubitus ulcer present on admission or when acquired after coming to a ward. (exception, HSC_D5 is excellent with documentation. Stage of ulcer is rarely documented in the chart.  Pat looks at the nursing FLOW SHEET for indication of some sort of a dressing change that would clue her in that there may be a bed sore. Pat will then track down a bedside nurse to find out what dressing is for and if bedsore what would be the stage.  Most time it is a guess because of poor documentation by both Doc and Nurse.[[User: PStein | PStein]]
 *** For critical care we can only put in 9 complications and bedsores is just not a top priority.  If this is important to capture then we would need to add it to our tmp file.  If the nurses don't chart skin breakdown there is no way to tell if it was there.  We can only use what is written down as sometimes we are looking at charts after the patient is discharged.  Documentation can be poor for this sometimes, I agree.  --[[User:LKolesar|LKolesar]] 12:55, 3 May 2010 (CDT)
+****At the Vic we have skin and wound asessment/intervention sheets that we check to see if pts have any problems also we check Patient care flow sheet to see if anything has been documented and also as above if we use up 9 complications this problem gets omitted also lack of nursing staff on the wards equals lack of documentation