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Purpose: A chart audit identified a deficit in wound assessment documentation by staff nurses in the Home Care setting. Additionally staff nurses were unable to make appropriate treatment decisions due to lack of assessment skills. A teaching tool was developed to standardize documentation, and facilitate the nurses’ ability to relate assessment parameters to appropriate wound care treatment.
Objectives:
Define a creative education method to teach wound assessment skills to staff nurses.
Identify a standardized format for wound care documentation to meet regulatory requirements.
Abstract: Statement of problem: An audit identified deficiencies and inconsistencies in wound assessment by staff nurses in the Home Care setting. Rationale: Medicare requires Home Health Care agencies to do a comprehensive wound assessment on each visit. Methodology: A retrospective chart audit of 25 wound care patients revealed only 2% compliance in identification of all seven wound care parameters (size, tissue type, exudate, edges, periwound, infection, and pain). A facility wide contest was held to create an acronym incorporating all seven wound assessment parameters. The winning acronym (Some Times Elephants Eat Pizza in Pajamas) was integrated into all levels of wound care educational materials and documentation. Simultaneously, a visual dressing selection guide was introduced. Nurses were then taught how to apply wound assessment skills in making treatment decisions using the visual dressing selection guide. Results: A follow up chart audit on 25 patients’ revealed 73% compliance in identification of all seven wound assessment parameters. It was also noted that wound description vocabulary was more concise and standardized. Conclusion: A creative wound assessment/treatment program can increase compliance in documentation, and improve staff nurse confidence in making wound care treatment decisions independently.