Response from the ANA
November 11, 2009
Dear Colleagues,
We appreciate your concern and interest in the issues surrounding assessment of patients admitted to acute care facilities and documenting the status of their skin integrity.
ANA's Standards of Nursing Practice for the profession identify the following:
Assessment: The registered nurse (RN) collects comprehensive data pertinent to the patient's health or situation.
* Diagnosis: The RN analyzes the assessment data to determine diagnoses or issues.
* Outcomes identification: The RN identifies expected outcomes for a plan individualized to the patient or the situation.
* Planning: The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes.
* Implementation: The RN implements the identified plan.
* Evaluation: The RN evaluates progress toward attainment of outcomes.
RNs and advanced practice RNs are expected to engage in these activities for each patient. Therefore, nurses should be recording their assessments, diagnoses, outcomes, and plans for the newly admitted patient. The documented details associated with the nurse's assessment of the patient's skin integrity will vary depending on their educational preparation and experience, with the wound, ostomy, continence nurse being the expert.
Assessment of patient skin is included in assessing the health status of individuals. Assessment of the skin includes identifying and staging pressure ulcers and differentiating them from other wounds. The purpose for identifying and staging a pressure ulcer and differentiating them from other wounds is to determine nursing care needs, plan for a strategy of care, and implement the care. Nursing information on pressure ulcers and staging is entered into the nurse's admission assessment and nursing notes. As such, nurses enter this information in the nursing record that is part of the medical record. However, nurses are not writing ICD codes on behalf of the admitting provider who has completed and reported his/her own assessment.
RNs would not be practicing outside their scope of practice if the nurse identifies the alteration in skin integrity as a pressure ulcer and stages it before the admitting provider.
We hope that this provides the necessary clarification for you and for anyone who raises this question in the future. Thank you for your time in your thoughtful concern and bringing this to us for clarification.*
-Rebecca M. Patton, MSN, RN, CNOR
ANA President
-Debbie Hatmaker, PhD, RN-BC, SANE-A
ANA First Vice President