Documentation
aSSKINg Bundles, Care Pathways and Wound Care Assessment/Wound Care Plans are all part of the patient’s medical records. It is important to assess the patient regularly and to record any observations within these records. All pressure ulcers should be documented, and all pressure ulcers Category 2 and above should be reported according to local reporting procedures. Furthermore, pressure ulcers/injuries should not be re-graded as they heal.
All practitioners must ensure that they are aware of local and national guidelines when treating patients with pressure ulcers/injuries or of those at risk of developing pressure ulcers/injuries.
The importance of accurate, timely and legible record keeping is highlighted by the Nursing and Midwifery Council (NMC) Guidelines for Record Keeping and the fundamentals are as follows:
- Help to improve accountability
- Show how decisions related to patient care were made
- Support the delivery of services
- Supporting effective clinical judgements and decisions
- Supporting patient’s care and communications
- Making continuity of care easier
- Providing documentary evidence of services delivered
- Promoting better communication and sharing of information between members of multidisciplinary healthcare team
- Helping to identify risks, and enabling early detection of complications
- Helping to address complaints or legal processes
(NMC, 2014)
Also, documentation must be completed for all pressure ulcers/injuries to comply with the NICE guidelines for pressure ulcer management (NICE, 2014). These guidelines state that all pressure ulcers categorised/staged at 2 and above must be reported as a clinical incident, which would result in a clinical incident form being completed.
The DoH (2009) has stated that there would be safer care for patients, who then could be confident that they would be protected from avoidable harm. Following on from this, the DoH identified pressure ulcers/injuries as an area to tackle. In 2010, the National Patient Safety Agency (NPSA) urged the NHS to take a zero-tolerance approach to the development of pressure ulcers/injuries. All NHS organisations now have a statutory duty to report serious patient safety incidents to the NPSA. This has since been made mandatory in April 2010. The development of a category 3 or 4 pressure ulcer is to be classified as a patient safety issue and will be recorded as a clinical incident (NPSA, 2010).
This section has shown the importance of assessment and classification in the prevention and management of pressure ulcers/injuries.