Legal Issues in the Care of Pressure Ulcer Patients - Medline

sttttttttttttsd. ChartingKey Concept: Good pressure ulcer documentation should include a wound description,measurement and wound care treatments as well as documentation of pressure redistributiondevices and techniques, including support surfaces and turning schedules.The patient’s chart is intended to be used contemporaneously with two other equallyimportant sources of information: the patient and the clinical team. For example, if a patient’swound size is not documented on a particular day, then that chart omission is clinicallyirrelevant because anyone with access to the patient can easily see the size of the wound.However, in litigation that may occur years after the event, the plaintiff may argue thatfailure to document wound size on a particular date means that the wound was neglectedthat day, adversely impacting the patient’s care.When it comes to clinical documentation, the “C”s have it. Good documentation is consistent,concise, chronological, continuing and reasonably complete. However, good documentationmust be balanced with good patient care. For example, in the course of caring for a patientwith a pressure ulcer, events such as explaining heel pressure offloading to the patient’sfamily, regular turning of the patient or daily skin assessments are not always entered intothe chart. Documenting every clinical action is not only an unreachably high standard, itcould compromise patient care if clinicians become more focused on creating perfect chartsthan caring for patients.Some facilities state that they practice “charting by exception,” recording only those eventsthat deviate from the norm but not documenting all standard care practices. Clinicians shouldbe cognizant that the charts they are handling today may be studied in the future in courtsof law and that legal decisions have often been based on what is not in the chart.Be consistent, document factual statements and use approved abbreviations. Would yourecognize this patient when you read the note seven years from now? Did you recordadverse events? Are the notes legible?The quality of documentation may make the difference between a plaintiff attorney’swillingness to pursue potential claims and a decision to decline a case. 23Assessment of a pressure ulcer is more than staging. Minimal documentation of pressureulcers, as described in Tag F-314 for long-term care facilities, includes (besides staging),location, exudate, pain, signs of infection and wound bed characteristics, such as typeof tissue and surrounding skin. 15sttttttttttttsLegal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers12