“Measurement Monday”: One Facility’s Approach to Standardizing Skin Impairment Documentation
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Photography may be a valuable tool to record pressure ulcer assessment, treatment, and prevention progress, but should not be considered a substitute for the written, detailed record.17
Quality improvement initiative. Before starting the initiative, all hospital policies related to pressure ulcers were reviewed. Consistent with AHCPR guidelines,3 skin assessments and documentation were to be completed on admission and every 8 hours thereafter. When skin impairment is discovered, the policy called for complete wound assessment and documentation, including descriptions and measurement. Follow-up measurements are to be completed weekly or more often if the wound deteriorates.
Retrospective chart audits for documentation of wound size and measurements for impaired skin (eg, open surgical incisions, skin tears, pressure ulcers, or lower extremity ulcers) in late 2005 showed that wound assessment documentation lacked appropriate details and content was inconsistent among nurses. Chart review results were shared with staff and members of the Skin Wound Ostomy Team Council. Brainstorming sessions were conducted with council members to develop a process for staff nurses to standardize the wound assessment process throughout all hospital units.
The concept “Measurement Monday” — a designated day of the week on which all wounds were to be completely assessed and documented — was proposed by a registered nurse team member and implemented. Wound measurement documentation was of particular importance. Thus, every Monday, nurses were to assess and measure all wounds. Care partners often assisted the nurse with patient positioning. Wound measurements were to be obtained using disposable measuring guides and the longest length by widest width technique and results entered into the progress notes. Wound assessment on the other 6 days of the week were conducted for the purpose of wound monitoring without measurement (ie, color, drainage, improvement or not).
Between January and March 2006, Measurement Monday education was provided to nurses on medical/surgical and intensive care units and included instruction regarding the use of a documented pressure ulcer staging system3 and wound size measurement techniques. Additionally, nurses were required to demonstrate accurate wound assessment, including measurement, to a WOCN or skin team member.
Subsequent random follow-up chart audits of patients with known skin impairments were completed from April through June 2006. This review showed wound size documentation was better but documentation of additional nurse-documented parameters such as measurement needed improvement. The hospital’s Nursing Quality Council began to assist with the effort to ensure a consistent assessment process. A registered nurse from this group developed a documentation tool, The Weekly Measurement Graph/Impaired Skin Integrity Tool (see Figure 1), to ensure appropriate assessment data were recorded. The tool is used to document each skin impairment on a weekly basis, including details of the wound assessment/measurement. This instrument was introduced to the nursing staff throughout the hospital in January 2007, at which time a review of previous education also was provided. Additionally, ruler reminders with the Measurement Monday logo were distributed to the nursing units for placement on assignment boards next to names of patients requiring wound assessments.
Random follow-up chart audits of patients with known skin impairments were again conducted between February and August 2007.
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