A Method for Consistent Documentation of Pressure Sores

摘要

To effectively prevent and manage pressure sores, healthcare professionals need an accurate assessment and precise communication of the status of skin and soft tissue. A study by French et al. (1983) found inconsistency in staff nurses' descriptions of pressure sores. Consistency in documentation was significantly improved immediately after a standardized teaching session, but these improvements were much less evident after 6 months. Based on these findings, a pressure sore flow sheet was developed at the authors' institution, the Rehabilitation Institute of Chicago, as a result of the study. The purpose of this form is to assist the nurse in conducting a more thorough, objective, and consistent evaluation of pressure sores. The form contains assessment parameters, key descriptor words, and a diagram with axes on which to draw the sore and label significant areas such as necrotic tissue. A grading key also is included on the form to ensure consistency in grading of pressure sores.