Incomplete documentation is the most common piece of evidence in a pressure sore related litigation case. It is impossible to use the defense that a pressure sore wasn’t avoidable if there is inadequate documentation. According to JCAHO (Joint Commission on Accreditation of Healthcare Organizations), the medical record should “reflect timely and proper medical and nursing intervention and treatment based on medical diagnoses.” [1]
Healthcare professionals must thoroughly document pressure ulcer assessments. Assessment forms and flow sheets will vary from facility to facility, and the time and details included can easily become lost or overlooked.
For example, the depth measurement is a common documenting gap. Most nurses overlook the depth of the wound and these measurements are frequently missing in the medical record. This is a common missing piece of documentation that can be used against a facility in the case of a litigation. Detailed measurements of the pressure ulcer should include:
• Measurements should be documented in centimeters and dated. (2.54cm equals 1 inch)
• Documentation with measurements in inches or related to objects for comparison such as a nickel or grapefruit is unprofessional and is not acceptable.
• Depth of the P.U. must be documented, otherwise the documentation is incomplete.
The exact measurements of a pressure ulcer is only one part of a very complicated documentation process. If any part of the required medical record is incomplete, it can be used to argue a poor assessment was performed. A poor assessment prevents proper planning, interventions, and treatments of a pressure ulcer. A nurse or doctor’s poor documentation can lead to a cascade of incomplete information that is passed on from healthcare professional to another, which may result in an overall poor prognosis.
The prevention of these cases should be a number one priority for all care facilities. However, if an unavoidable pressure should develop, detailed documentation should be provided to prevent any possible liability. For more information on wound documentation software that can help prevent pressure ulcer and the common documentation errors associated with them, visit woundrounds.com.
[1] National Nurse Consultants, Inc. The Attorney’s Quick Guide: “The 6 Essential Elements of Pressure Ulcers You Must Find in the Medical Record.” HGexperts.com. Web. 04 September 2012.
