Documentation
of Skin/Wound Problems
with SAEnCompass and MDS 3.0
Assessment:
1.
On Admission:
a.
During shift of admission the skin
risk assessment will be done and documented in Assessment Editor.
b.
The head-to-toe exam of the resident’s
skin will be done within the first 24 hours and documented in the LTC Physical
in the Assessment Editor (AE) area or in a charting entry.
c.
If any lesions are present, each
will be recorded as a skin incident in the Risk Incidents (RI) area.
2.
On-going assessment and evaluation:
a.
Each quarter the Skin Risk
Assessment in AE during the reference period and the LTC Physical in AE will be
a part of the part of the quarterly Comprehensive Assessment update and care
plan review.
b.
Each resident will have a weekly
assessment of skin condition. A treatment order for “Weekly Assessment of
Skin Condition” will be entered (Type = SA Type/Skin/Wounds) in Orders and
Conditions (OC) for each resident. Each week the results of this
assessment will be entered in Shift Entries, Skin/Wounds. (Note that if the
resident has no existing skin incidents documented in RI, there will not be a
Skin/Wound to select from the drop-down list for this S/W Treatment.)
3.
In the event of a skin/wound problem
develops or is present at admission:
a.
A treatment order will be entered
(Type = SA Type/Skin/Wounds) if needed in Orders and Conditions (OC).
b.
A skin/wound event will be entered
in the Risk Incidents (RI) area of SAEnCompass
to document the initial discovery or the condition on admission.
This will allow the treatment in 3a above to be linked to the specific
skin/wound. Click on the button to go to the AE
area and do an updated Skin Risk assessment.
c.
The follow-up and progress charting
for all skin/wounds will be documented in the Shift Entries area Skin/Wound
tab.
i. Documentation of
observation and treatment of a skin/wound will be done at least daily in Shift
Entries, Skin/Wound tab; the assessment and comment field will be utilized.
ii. Measurement of the
skin/wound will be done at least weekly, including drainage, etc.
Care Plan: