pressure ulcer staging conflicts and resolutions
Because of the ability to code the stage of an ulcer from nursing documentation, what are institutions doing to get a good staging assessment by both nurse and doctor? Are any institutions utilizing more of a descriptive assessment in cases that nursing may not be confident in their staging assessment or any other processes that get all care providers on the same page?
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Our organization designates pressure ulcer staging specifically to the Wound/Ostomy Care (WOC) nurse who has a template to describe the location, POA status, describe the size and depth/layer of the ulcer, likely etiology if no pressure (venous, diabetes) and surrounding tissue and treatment. If it's one of our smaller facilities they have a designated RN who rounds on patients and stages. The primary nurses had too much variation in their assessments. The providers are educated to cross check what the WOC RN is documenting to avoid a query since they are ultimately responsible for documenting each ulcer location, etiology and POA status.