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Physician Records Critical in Stage III/IV Pressure Ulcers

March 16, 2008
Written by: , Filed in: Practice Management
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Stage III or IV pressure ulcers acquired after admission to a health care
facility are incredibly controversial ‘never events’ items because skin
breakdown may still occur despite best efforts to maximize care and protect
the skin.

Several items on the ‘never events’ list developed by the National Quality
Forum regarding serious medical errors are considered to be controversial.
Perhaps the most controversial item is that of Stage III or IV pressure ulcers
acquired after admission to a health care facility.

This is an incredibly controversial item because, when a patient comes through
the door, we often have an individual with poor nutrition who is immobile or
who is so sick or injured that we do not have the ability to turn them, to
reposition them, to perform the proper skin care, or to do all the treatments
required to keep their skin healthy and intact. Despite best efforts with
maximizing nutrition, using specialty beds and overlays, and providing all
sorts of other things to protect the skin, breakdown occurs.

When these patients enter the hospital, their arrival condition must be
carefully documented. They may already have an ulcer or may be starting to
develop one on arrival. This must be documented, and perhaps even
photographed, because this condition is on the ‘never events’ list.

Your patient’s lawyer will argue that these pressure ulcers should never
happen, despite all the problems that you have pointed out in dealing with
these patients. Most likely, the patient’s lawyer will take photographs of
these horribly ugly ulcers and blow them up into a big poster to show to a
jury.

With these ulcer cases, we have found that our hospital documentation is
generally poor, meaning we may have provided all the appropriate care,
including a consultation from appropriate nursing personnel, but we either did
not document this care or did not document it well. It is difficult to prove
appropriate care when there are holes or gaps in the patient’s medical record.

In the world of documentation, “present on admission” documentation is
recognized only if a physician documents it. Even if the hospital has provided
excellent care for the condition, proving adequate care will become more
difficult from a legal perspective unless the physician includes that
patient’s skin condition on admission and the subsequent care in his or her
notes.

Therefore, the physician needs to talk to all involved health care team
members and to consider the information they are providing, particularly when
it comes to skin issues. This is one of the places where physician
documentation often becomes the center of attention. This is especially true
with elderly or incapacitated patients who are bouncing between nursing homes
and hospitals. In these cases, blame for the ulcer is often placed on the
other care facility.

Reference
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Stage
III or IV Pressure Ulcers Acquired After Admission to a Health Care Facility.

Stage III or IV pressure ulcers acquired after admission to a health care facility are incredibly controversial 'never events' items because skin breakdown may still occur despite best efforts to maximize care and protect the skin. Several items on the 'never events' list developed by the National Quality Forum regarding serious medical errors are considered to be controversial. Perhaps the most controversial item is that of Stage III or IV pressure ulcers acquired after admission to a health care facility. This is an incredibly controversial item because, when a patient comes through the door, we often have an individual with poor nutrition who is immobile or who is so sick or injured that we do not have the ability to turn them, to reposition them, to perform the proper skin care, or to do all the treatments required to keep their skin healthy and intact. Despite best efforts with maximizing nutrition, using specialty beds and overlays, and providing all sorts of other things to protect the skin, breakdown occurs. When these patients enter the hospital, their arrival condition must be carefully documented. They may already have an ulcer or may be starting to develop one on arrival. This must be documented, and perhaps even photographed, because this condition is on the 'never events' list. Your patient's lawyer will argue that these pressure ulcers should never happen, despite all the problems that you have pointed out in dealing with these patients. Most likely, the patient's lawyer will take photographs of these horribly ugly ulcers and blow them up into a big poster to show to a jury. With these ulcer cases, we have found that our hospital documentation is generally poor, meaning we may have provided all the appropriate care, including a consultation from appropriate nursing personnel, but we either did not document this care or did not document it well. It is difficult to prove appropriate care when there are holes or gaps in the patient's medical record. In the world of documentation, "present on admission" documentation is recognized only if a physician documents it. Even if the hospital has provided excellent care for the condition, proving adequate care will become more difficult from a legal perspective unless the physician includes that patient's skin condition on admission and the subsequent care in his or her notes. Therefore, the physician needs to talk to all involved health care team members and to consider the information they are providing, particularly when it comes to skin issues. This is one of the places where physician documentation often becomes the center of attention. This is especially true with elderly or incapacitated patients who are bouncing between nursing homes and hospitals. In these cases, blame for the ulcer is often placed on the other care facility. Reference Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Stage III or IV Pressure Ulcers Acquired After Admission to a Health Care Facility. [text_ad]
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