Nurses vs Doctors Documenting Ulcer Stage

bbogda@morrishospital.org

I am having a discussion with nursing staff here about staging pressure ulcers.  I am told that they would rather the doctors document their own assessment of the ulcer stage as they believe their documentation is not sufficiently consistent.  They do have a wound care team which I find odd, and I would like to suggest some training ( I was going to say advanced, but I think it is basic nursing).  Before I go forward with this, I am curious to know if their are other facilities out there that don't allow the nurses to stage ulcers and leave this as a doctor's responsibility.

evanspx@sutterhealth.org

I can state to you that we have RNWC staff and they document the precise staging and we do reference these notes for coding and CDI purposes.  I would also state this has been the case at every site I have worked or consulted - by that, I mean,  if the MD documents the presence of the pressure ulcer,  the coding staff (and CDI) pick the staging from the WC RN.  On that occasion a WC RN does not see the patient, we still will code the stage when noted by an RN given this is within the scope of practice of an RN.  Hope that helps?

drew.siegel205

Same here. As long as a clinician confirms the presence of the ulcer and location, then nursing notes are used for staging.
Don't forget to query for Present on Admission (POA) status. The clinician must determine this and document it, even if it is obvious from nursing notes. 

evanspx@sutterhealth.org

I would strongly advise that the RN staff continue to evaluate and document the various stage of each ulcer.  Astute coders often rely upon the specific RN documentation to assign the correct staging information.  Also, CDS, can, and should, refer to RN notes in the context of a query to clinicians. In my personal experience, the RNs consistently document the stages more precisely than any other clinician.   It might help their morale a bit to show them examples of how and when the documentation they render assisted in the proper reporting of ulcers.  The reporting of ulcers and POA status has important medicolegal implications and also implications for various state reporting agencies.