Perioperative Wound Assessment and Documentation

Perioperative Assessment tool-

The renewed focus on early assessment and documentation of all pressure ulcers ,especially Deep Tissue Injury (DTI) ,by CMS resulted in a review of our facilities perioperative wound assessment and documentation policy. The operating room is one of the locations documented in current research for at risk patients to develop a DTI. The perioperative team at Norwalk Hospital expressed a wish to be proactive in preventing the occurrence of pressure ulcers in the operative patient census. The team also wanted to have a system in place for accurate timely assessment of skin during each phase of the perioperative period. The team consisted of the hospital wound care nurse, the OR and PACU managers and the OR  Director and educator.  The initial goals were to obtain an accurate pre-op skin and wound assessment, document those patients at increased risk for breakdown and provide consistant assessment and documentation during the entire perioperative period.

A team was selected to explore the existing information on operating room acquired pressure ulcers. We were able to obtain a pre-existing OR assessment tool and elected to build an expanded perioperative form to include pre-op assessment in the holding area, intraop assessment to be assessed in the operating room and a post-op assessment to be performed in the PACU. The form needed to be one sheet of paper, easy to use, with a checkbox system of documentation to encourage acceptance of a new assessment tool.

This poster will review the process of designing and implementing this tool.