The Evaluation of a Newly Developed “One Minute Pressure Ulcer Documentation Tool”

Health care professionals are required to document wound care management, however this is not routinely done in our institution leading to patient safety issues and increased cost to the institution.  There is the potential for litigation unless thorough wound care documentation is completed throughout the continuum of care.  Evidence is overwhelming that effective documentation and management of all types of wounds is necessary for improved outcomes.  According to Reddy, Gill, Rochon (2008), pressure ulcers present a common but potentially preventable condition seen most often in high-risk populations, however documentation by the nurses was less than ideal.  Gunninberg, Lindholm, Carlesson & Sjoden (2001), reported that nurses fail to document according to mandated guidelines. Gunninberg et al (2000) suggested that nurses are unfamiliar with expressing their actions in regards to documenting pressure ulcer management.
To address the need for improved pressure ulcer documentation the “One Minute Documentation Tool for Pressure Ulcers” was developed and trialed on four inpatient units in an acute care facility. The purpose of the tool was to facilitate effective communication between the interprofessional team and improve documentation.  An extensive educational program was offered prior to the implementation of the tool.
The overall findings of the study demonstrated that pressure ulcer documentation improved when the standardized tool was utilized.  The study provided an opportunity to enhance staff knowledge about pressure ulcer management, voice their wound care concerns, and facilitate dialogue about pressure ulcer care.  Staff nurses appreciated and continued using the standardized tool after the completion of the study.