Improving Skin Assessment Documentation in the Electronic Health Record to Prevent Perioperative Pressure Injuries

ABSTRACT Perioperative leaders at a pediatric trauma hospital initiated an examination of the existing processes for pressure injury prevention. They assembled a workgroup comprising a wound and skin clinical nurse specialist, a nursing informatics specialist, and a perioperative nurse specialist who applied a proven change management framework to guide their efforts. The workgroup identified a critical gap in the documentation features in the electronic health record: nurses were unable to communicate skin assessment and pressure injury information easily and consistently across services (eg, inpatient, emergency department, surgical services). Using evidence from nursing and pressure injury associations on skin assessments, interventions, and documentation, the workgroup developed, trialed, and implemented updated documentation fields, making them consistent throughout the electronic health record. Based on postimplementation survey responses, nurses at the hospital are highly satisfied with the changes. The surgically acquired pressure injury rate at the hospital continues to remain low.