Skin and Wounds: The Documentation That Can Save Your Nursing License

Wound care and skin integrity are areas of nursing that can quickly become legal minefields. Pressure ulcers and other skin injuries can lead to lawsuits, especially if the patient or their family believes the injury could have been prevented.

Recognizing High-Risk Patients

Patients who are immobile, have poor nutrition, or are elderly are at a higher risk of developing skin breakdown. Early identification and intervention are key. Always assess skin integrity during each shift and document your findings.

Solution: Develop a routine for regular skin assessments, particularly for high-risk patients. Use validated tools like the Braden Scale to assess skin integrity and document any changes or concerns immediately.

What to Document

If you notice any signs of skin breakdown, such as redness, blanching, or wounds, document the exact location, size, and appearance of the area. Include details of the care provided, such as repositioning, the application of dressings, and communication with the care team.

Solution: Maintain a high standard of documentation that includes not only the condition of the skin but also your interventions and patient education. If skin issues persist, document your communications with the healthcare team about further interventions.

Why Documentation Matters

In the event of a lawsuit, your documentation will be scrutinized to determine if you followed the standard of care. If your notes are incomplete or inconsistent, it could be interpreted as negligence, putting your license at risk.

Solution: Make documentation a priority. If you're ever in doubt about whether to document something, err on the side of including it. Ensure that your notes are clear, concise, and reflect the care provided.

Prevention is Key

Following your facility's protocols for skin care, using preventive measures like turning schedules, and documenting your actions can help prevent skin injuries and protect your license.

For more on wound care documentation and how to protect your nursing license, check out educationalnurse.com.