Pressure Ulcer (PU) Documentation and a New Electronic Health Record (EHR): Trials, Tribulations and Triumphs

Purpose:

Sixteen months ago, the hospital system converted to an integrated system wide electronic health record (EHR) which presented challenges in the daily work flow of nursing staff. Chart audits revealed inaccurate pressure ulcer (PU) staging, treatment documentation not corresponding with orders and inconsistent wound measurement. Nurses struggled with the complexity of the PU EHR components.

Objective:

This quality improvement project promoted the accurate staging of pressure ulcers, initiation of nursing skin care protocols, identification of medical device related PU risks, selecting the appropriate treatment and comprehensive PU EHR documentation to enhance patient outcomes.

Practice Innovation

The quality improvement project included: (1). Policies for wound measurement guidelines and initiation of skin protocols were created; (2).   Medical device PU inservice presented to ICU staff and pressure ulcer prevention (PUP) team; (3). Nurse Practice alerts were distributed focusing on activating the skin protocol, ensuring consistent treatment documentation and skin workflow tips; (4).   The EHR system wide clinical informatic team sent top tips on utilization of the skin protocols and accurate PU documentation; (5).  The PUP team demonstrated EHR PU documentation competency in computer lab; (6).  PU housewide monthly and weekly ICU audit results were distributed to nursing administration along with action items; (7).  Individualized RN EHR education was provided by the Ostomy/Wound RNs; (8).   All ICU RNs participated in a PU Competency which reviewed staging, treatment, nutrition, respiratory device PU, and entering results into an EHR practice environment.

Outcomes

RNs report increased confidence in EHR usage with improved PU documentation. PU Audit results have shown an increase in comprehensive PU documentation and measurement, though opportunity still exists for PU orders to coincide with documented treatment. Ongoing EHR education continues at the unit/ committee level.  We anticipate documentation will continue to improve as RNs continue to be more familiar with the new system.