Pressure injuries

dallend@einstein.edu

HI - we are having discussions regarding pressure injury staging with our wound care specialists and the nursing department.

Here is an example:

A patient was discharged a week ago with a stage 4 sacral pressure injury.

The patient is readmitted this week - the sacral injury is still present - the nurse who does the admission assessment document the current stage of the wound as a stage 3.  Stage 3 is documented for the past 3 days.  Wound care sees the patient and states that since the wound was a stage 4 during a previous admission it should always be documented as a stage 4 until it is healed. The nurses who saw the patient apparently were not aware of the documentation during the previous admission  She stated that this is the NDNQI guideline - I have reviewed the guideline and I do understand their rationale.

Nursing is asking me if they should go in to the EHR and update all of the stage 3 documentation to Stage 4. 

I referred them back to the nursing department. 

Does anyone else have this issue? 

lprescott1

it is correct that it should be documented as a healing stage 4- if in the record there is inconsistencies or conflict I would suggest you query the provider to document healing stage 4- present on admission.