Nursing Required Documentation

For acute inpatients, initial screening must be completed within 24 hours of admission, ideally within 8 hours for both adult and pediatric patients. See Risk Assessment & Reassessment Frequencies for more details.

There are certain nursing documentation requirements that are flagged and are reported when they have not been completed. These flagged notifications show up in the Nursing Sidebar Required Documentation section, and in the Required Doc report from the patient list. Within the nursing Required Documentation, skin risk is flagged under 36 hours.

Skin risk screenings, both Braden Scale and Glamorgan Scale can be documented via:

• Nursing Admission Navigator (this is the ideal place of documentation for initial screening)

• Flowsheets (Nursing Screenings, Basic/Complex Assessment, Ped Assessment, etc.)

Pressure Injury Risk Screening Documentation

There are several flowsheets with the Skin Risk section where pressure injury risk screening can be documented. The metric evaluates values stored in one of the following flowsheet rows, which are automatically calculated upon completion of all of the risk components:

• Braden Total Score (FSD 1000 = 305180)

• Glamorgan Total Score (FSD 1000 = 3040800052)

Pressure Injury Risk Screening

Description

• Proportion of inpatients with pressure injury risk screening completed.

Denominator

• Number of Patient Encounters where:

  • ADT Patient Class (EPT 10110) = Inpatient [101] AND

  • Patient Status (EPT 10115) = Admission [2] OR Discharged [3] AND

  • Level of Care (EPT 10135) = Acute [1] AND

  • Admission Effective Instant (EPT 10290 10291) = User specified date of admission

  • Observation occurs between admission instant (ADT 59) and discharge instant (EPT 18855 and EPT 18856)

Note 1: Patients whose admitting unit (ADT 50) is Emergency Department type, with status of emergency inpatient (EIP) are included in the denominator under ED unit where the documentation took place. 

Note 2: Patients who have been admitted for less than 24 hours are not included in the metric, but added back when 24 hours has passed. This impacts reporting period of yesterday, but negligible for other periods. 

Numerator

• Number of Patient Encounters in the denominator where:

  • Braden (FSD 1000 = 305180) or Glamorgan (FSD 1000 = 3040800052) flowsheet documentation instant (FSD 1010) MINUS the Date and Time When First Inpatient (EPT 10290 10291) IS LESS THAN OR EQUAL 24 hours.

Note: The time when patient first became inpatient is triggered when the admit order is released.

Calculation

• Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point

Filters

• Hospital Specialty Service: ADT 70 - CATEGORY - (e.g., General Internal Medicine [106])

• Hospital Unit: EPT 18880 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])

• Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])

Note: Hospital Unit is defined as the patient encounter department where the flowsheet row was first documented. If documentation does not exist, it’s defined as the current encounter department for admitted patients (EPT 18880), and last encounter department for discharged patients (EPT 18880).

Analytics Definition

• Crib-Sheet: Pressure Injury Risk Screening Metric Definition

Timeliness

Pressure Injury Risk Screening metric is currently calculated for admitted or discharged patients, is retrospective (or delayed by several hours for admitted patients), and so does not necessarily help with current status of required organizational practice. The metric can help teams set goals for behavior (meaningful use) and process changes but cannot be used for real-time observation of behavior change. For real-time monitoring, staff can review the Required Doc report in the patient list, and managers can refer to the IP Operational Safety and Quality dashboard.

Radar Dashboards

Reporting Workbench

Slicer-Dicer