Documentation of Pressure Ulcer Wounds and Advantages of EMR

Pressure ulcers are serious and a common problem in elderly people and so are pressure ulcer wounds. Proper knowledge of the patients’ condition is important to find out the nature of the wound and its complications to speed up the healing process. Wound care specialists can understand this only with the comprehensive documentation of pressure ulcers. With structured and standardized clinical information, Electronic Medical Records (EMRs) are found to be more effective in assisting clinicians to make key decisions quickly than paper-based records. Before looking into the advantages of EMR, let’s explore the documentation requirements for pressure ulcers.

Key Components of Pressure Ulcer Documentation

According to the National Pressure Ulcer Advisory Panel (NPUAP), the following are the major components that should be included in the charting that describes pressure ulcers.

  • Location – This indicates the extremity, nearest bony prominence or anatomical landmark and is very important for appropriate monitoring of wounds.
  • Stage – As per NPUAP, pressure ulcers are classified into six different stages such as Stage I, Stage II, Stage III, Stage IV, Unstageable and Tissue Injury (Suspected Deep). With this, clinicians can understand the severity of pressure ulcer wounds and their complications to determine more effective wound care treatment.
  • Dimensions – These include the length, width and depth of the wound. They should be recorded in centimeters and documented in the order length, width and then depth.
  • Undermining/Tunneling – This should also be recorded in centimeters and measured by the clock method (measure as if the resident is on a clock with the resident’s head at 12 noon). In case of sinus tract/tunneling, depth of the tract or tunnel is measured and then the direction of the tract or tunnel is given by clock method. If there is more than one sinus tract/tunnel, each of them needs to be numbered clockwise.
  • Wound Base Description – This describes the appearance of the wound bed such as granulation (pink or beefy red tissue with a shiny, moist, granular appearance), necrotic tissue (gray to black and moist), eschar (gray to black and dry or leathery in appearance), slough (yellow to white and may be stringy or thick and may appear as a layer over the wound bed) or epithelial (new or pink shiny tissue that grows in from the edges or as islands on the wound surface). If the wound base is a mixture of these appearances, record the percentage of its extent (for example, 75% granulation tissue with 25% slough tissue).
  • Drainage – The amount (scant/small, moderate/medium or copious/heavy), color/consistency (serous, serosanguineous, purulent, or other) and odor (if present or not) of drainage should be documented here.
  • Wound Edges – The area up to 4 cm from the edge of the wound should be described here. Measurement should be recorded in centimeters. Describe the characteristics ((light pink, deep red, purple, macerated, calloused and more) of the area as well.
  • Odor – Document whether odor is present or not.
  • Pain – If the patient has pain associated with the wound, document those details along with the interventions.
  • Progress – Document the progress in patient as Improved, No Change, Stable or Declined.

Major Benefits of EMR

  • Researches have shown that nurses document much less than what they actually provide to the patients. However, pre-formulated templates with EMR remind nurses of reporting the pressure ulcer stage, size, location, risk assessment, diagnoses, goals, and planned interventions. An electronic system can enhance the completeness and comprehensiveness of patients’ wound care records.
  • Improved communication is another major advantage with EMR. In a paper-based record system, when the nurses complete recording pressure ulcers, the assessments are available for review in the hospital records. If there are no specific notes to the physicians in the records, they will remain unaware of these significant findings. If there is an EMR having an interface for physicians that is connected to the interface for nurses, then physicians can access pressure ulcer findings with just a few clicks.