Pressure Ulcer Nurse Explains How the Medical Record May Reveal Lapses in Skin Assessments - Or Not!

A few months back, I received another set of medical records to review and analyze for a great attorney-client of mine. It was a case about a stage IV pressure ulcer (also known as decubitus ulcers) that a patient had developed during a hospital stay.

Sounds familiar doesn't it? They all do.

PRESSURE SORES STAGES

But there was something very different about this case.

As a nurse, I have reviewed thousands and thousands of medical records; and when I started my review of this large stack of medical records, I noticed that there were great photos in there!

Now, I don't mean great photos as when you go to an amusement park, because these were photos of a stage IV pressure ulcer (the worst type of pressure ulcer you can develop!). I mean these were great photos because they painted the story of what really happened.

Most healthcare facilities; depending on their protocols, have now resorted to using photography as another way to document pressure ulcers. Photographing pressure ulcers in different stages, can be very helpful and beneficial to the healthcare providers because the may be able to determine if the pressure ulcer is healing, getting worse, or if it has remained unchanged.

But there are also disadvantages when photographing pressure ulcers.

The healthcare provider needs to remain consistent and continue to photograph the wound per protocol. An occasional photograph of the wound usually has no benefit.

Photographs of pressure ulcer that are taken too closely or from a distance may be difficult to use to assess the site. Photographs that are not timed and dated can de difficult to match up with the written portion of the documentation that describes the wound. Also, the location of the pressure ulcer must be documented on the photo; especially if the patient has wounds in different part of the body.

So, what was the real story that these great photographs revealed? The photos in the medical record I was reviewing and analyzing became the "unwritten" timeline that perfectly showed us in full-color how this pressure ulcer came about. Needless to say, my attorney's client was very pleased at the final outcome of this case! Great pressure ulcer documentation through photography can be beneficial to either the plaintiff or the defense.

Pressure Ulcer Nurse Explains How the Medical Record May Reveal Lapses in Skin Assessments - Or Not!

PRESSURE SORES STAGES