Implementation of an Electronic Medical Record: Emergency Department Documentation of Pressure Ulcers Present-on-Admission

Objectives:

After viewing this poster, the viewer will be able to:

1. Identify two benefits of electronic medical record (EMR)
2. State why pressure ulcers present-on –admission (POA) should be staged in the emergency department (ED)
3. Describe the process of enhancing hand-off communication between ED nurses and wound care nurse practitioners regarding pressure ulcers POA.

Our Challenge:

Patients from the community and nursing homes are transferred to our facility with multiple full-thickness pressure ulcers. Before implementing an EMR, the ED’s paper documentation of pressure ulcers allowed for delays in notifying the wound care NP and limited the ability to assess the accurate ED nurse staging documentation. A process was needed to improve the  effectiveness of capturing of all patients admitted with Stage III and IV pressure ulcers and improve communication with the wound care NP about the admitted patients.

Improvement Plan:

A meeting was arranged with ED nurse leadership and the system analyst to review the CMS POA guidelines. A program implemented which generated a report on all patients admitted with pressure ulcers. Along with demographic information the report included the location and stage of all pressure ulcers. The report was provided to the wound care NP and used to determine the accuracy of pressure staging in the ED.

Outcomes:

• During the first nine months the ED staff correctly staged 80% of full thickness pressure ulcers.
• There was an increased awareness about the importance of documenting pressure ulcers present-on-admission.