Utilizing Computerized Documentation in Pressure Ulcer Quality Initiatives

The purpose of this poster is to demonstrate how a 200 bed community hospital uses the electronic medical record and computerized nursing documentation for quality initiatives relating to pressure ulcer prevention.  The objectives for these initiatives were to:  a) improve the quality of nursing skin assessment documentation, b) to reduce pressure ulcer incidence and c) streamline the pressure ulcer prevelance surveying process. 
     The WOC nurse first collaborated with key nursing staff and the information technology department to improve the facility's skin assessment and pressure ulcer prevention documentation.  Next, we developed a daily report that identifies by nursing unit the patients at risk for pressure ulcers, and includes nursings' assessment of the sacrum and heels.  This report is distributed to the unit or "pod" managers and was instrumental in decreasing our pressure ulcer rates.  In addition, we used the computerized nursing documentation along with other sections of the electronic medical record (EMR) to create a report that streamlines the cumbersome data collection process for a yearly international pressure ulcer prevelance survey.
     The poster includes samples of our nursing skin assessment and skin protection measure screens, as well as examples of how these are used for surveillance and quality monitoring.  Also included is an example of the customized report used to identify at-risk patients, as well as the data report generated for the pressure ulcer prevalence survey.
     The author hopes this poster will encourage other facilities to consider how they may use computerized nursing documentation and the EMR to assist in their pressure ulcer quality initiatives.