Documentation Tips in Pressure Injury Prevention

Kathleen Martin RN, MSN, MPA, LNHA, CPHQ, WCC, HACP
Pressure Injuries
Documentation Tips in Pressure Injury Prevention

Kathleen Martin, RN, MSN, MPA, LNHA, CPHQ, WCC

Documentation should aid communication and is the vehicle by which healthcare professionals share information between members of the multi-professional team responsible for the care of an individual. Effective documentation should provide evidence of the services and care delivered, showing how decisions related to patient care were made, and by so doing ensure continuity and consistency in care provision.

Nursing documentation should, but often fails to, demonstrate the rational and critical thinking that underpin clinical decision making and interventions while also providing a timeline for patient care and progress. There is no standardized format for documentation and a number of frameworks exist to assist nurse including narrative charting, clinical pathways, problem- orientated records and care-element focused notes



Much of nursing documentation around the US, is still done in hand-writing. Irrespective of the documentation system employed, your basic notes should be:

  • Contemporaneous
  • Accurate
  • Objective
  • Legible
  • Free of:
    1. Grammatical/spelling errors
    2. Abbreviations
    3. Errors/erasures
    4. Initial and date/time any alterations Completed in blue or black ink
  • Dated, times and signed: Print name

Guidelines (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance [NPUAP], 2014; National Institute for Clinical Excellence [NICE], 2014) state that pressure ulcer risk assessments are an ongoing process that should be undertaken at first patient contact and should be repeated regularly, if the patient moves between care facilities, including ward areas, or if their medical condition changes. Guidelines (NPUAP, 2014; NICE, 2014) also demand that patients have an individualized care plan that reflects this risk assessment and that it is regularly reviewed and adapted to accommodate changes in their medical condition or social situation. Deviations from local or national guidance or the agreed care plan should be clearly documented and the rationale for those actions noted.

Pressure ulcer documentation should record linked areas of care:

  • Skin assessment and damage categorization
  • Risk assessment
  • Care plan
  • Pressure ulcer wound care.

These should be integrated with other care strategies such as nutritional status, use of devices and hosiery for deep vein thrombosis prevention. Modern care provision focuses on the role of the multidisciplinary team.

How good are our notes?

Based on my case reviews over the years, these common failings continue to show up:

  • Variation in the type and quality of the assessment and care documentation and structure between institutions and even within institutions
  • Failure of  accurate  and  specific  initial risk assessment
  • Failure to repeat adequate skin and risk assessments
  • Failure to determine the correct etiology and category of a wound
  • Inconsistency among staff
  • Using and failing to complete adequately/ consistently multiple documentation forms
  • Lack of empowerment to report abnormal

Skin Assessment

Basic skin assessment should record skin integrity, especially in areas of pressure, color changes and discoloration and variations in temperature, firmness or moisture and take into consideration any pain or discomfort reported by the patient (NICE, 2014). Initial assessment should occur as soon as possible (within 8 hours of admission or at first contact in the community) and be repeated as part of an ongoing risk assessment process, the frequency being defined by the clinical setting, and individuals, risk and changes in their clinical status. Skin status should also be recorded on discharge or transfer to another care setting (NPUAP, 2014; NICE, 2014).


Photo-documentation of pressure damage is a useful communication tool and can assist in assuring consistent pressure ulcer categorization; it can also help in patient communication.

The photograph should be of good quality and be accurately labelled, which should include the date, time and patient ID and a measurement scale and color reference.

Risk Assessment Scores

A variety of risk assessment tools are available to assist in patient assessment and risk prediction. Of those available, the most commonly used in a hospital setting is the Braden score. This is meant to be as objective as possible, but I continue to see nursing staff misjudge, and score inappropriately. I recently had a case where staff scored a patient as a low skin risk when the patient already had a sacral pressure injury. How can the patient be low risk?

Care Plan

There are multiple types of documents available. Not all record the required detail that truly provides continuity and safe practice. The most common problems are:

  • Incomplete initial assessment
  • Unrealistic care plans that lack a clear objective
  • Incomplete or absent evaluation.

To conclude this brief piece, pressure injury prevention documentation must allow individualized patient-specific details to be recorded by the whole multidisciplinary team. Pressure ulcer risk assessment and prevention is rightly regarded as a quality indicator and safety issue within the healthcare community.


National Institute for Clinical Excellence: (2014) Clinical Guidelines CG179: Pressure Ulcers: Prevention and Management of Pressure Ulcers. Available at: pressure-ulcers-prevention-and- management-of-pressure ulcers-pdf


National Pressure Ulcer Advisory Panel: European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014)  Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Osborne Par

Western Australia: Cambridge Media

Kathleen possesses over 30 years nursing experience in a variety of clinical and administrative roles in settings that include Nursing Homes/Long Term Care, and in hospital settings. Past and positions include clinical oversight of Critical Care, Endoscopy, Post Anesthesia Care Unit, Long Term, Sub- Acute Care, Ventilator Units as Director of Nursing and as a Licensed Administrator, as well as other health care titles. She currently works per diem in wound care . She has also held executive positions in Quality Management in Hospitals where she had oversight of related areas in the hospital setting. Kathleen possess extensive experience regarding the regulatory standards put forth by Centers for Medicare and Medicaid Service, Departments of Health and Senior Services, and the Joint Commission. In addition, she is Certified by Health Care Quality Board and hold a CPHQ {Certified Professional in Health Care Quality}, and possess a Wound Care Certification. Kathleen has published several professional articles; book chapters, and authored a book “60 Forms for LTC”.

Information is courtesy of Nancy Morgan Wound Care, copyright 2023.  

DISCLAIMER: All clinical & legal information, text and graphics, in this blog are intended to assist with determining appropriate wound therapy or proper legal information. It is not intended to be a substitute nor constitute providing legal or medical care or advice, diagnosis, or treatment. Responsibility for final decisions and actions related to legality and care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians and their legal representation. Individuals should always contact their healthcare providers for medical or emergency-related care and/or contact their retained attorneys or their legal representation.


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