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Watch your language: Culture change for the medical record

April 24, 2012
by Daniel Moles, RN, BBA, MPS, LNHA
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Words used by long-term care professionals do far more than document observations, symptoms and events. They plant perceptions in the minds and hearts of care residents, caregivers, regulators and payers.

Words matter. Consider this one: “bedsore.” Say it aloud. Hear it. Write it. Instantly, bedsore defines a wound, creates an image, angers families, saddens guilt-ridden caregivers, motivates citation-seeking surveyors and may enable payers to reduce reimbursement.

Picture a bedsore. Stare at it. Now, focusing on that same image, re-label it “skin failure.” Suddenly, the identical wound no longer looks or ‘feels’ the same.

This article offers suggestions for modifying commonly used words and phrases to clarify what is communicated to residents, families and others. Think of it as culture change for the medical record.

A ‘FAILURE’ LIKE ANY OTHER

Clinicians should adopt the selective use of “skin failure” to communicate that the skin is an organ, and like other organs, it is prone to failure. Interestingly, our society accepts that as adults age, they may succumb to heart, kidney and other organ failures. When a 90-year-old patient at the end of life dies of heart failure, oversight agencies do not tag the cardiologist with multiple deficiencies. Should that same resident develop a “pressure ulcer,” however, surveyors will cite and raging relatives will sue.

The National Pressure Ulcer Advisory Panel recently recognized that “skin failure” exists. Skin failure is associated with hypoperfusion (diminished blood flow), particularly in residents at end-of-life and in those who demonstrate failure of vital organs.

Residents have a right to be fully informed of their total health status. “Fully informed” includes telling the resident (authorized representative) when an unwelcome outcome may reasonably be anticipated. As residents near the end of their lives, especially those who refuse food and beverages—a request that is often followed in accordance with advance directives—caregivers should fully inform families that organs might fail, including the skin. For such residents, adjusting the goal of the care plan to reflect the limited benefit of interventions that are otherwise intended to reduce the likelihood of skin failure may be appropriate. Professionals should document when, “Complete wound closure may not be realistic because....” and “Wounds may develop and may not heal due to....”

And not every wound over a bony area is a classic “pressure ulcer.” Some, especially foot wounds, have multiple causes. An ankle or heel ulcer may be symptomatic of severe peripheral atherosclerosis. “Skin ulceration or frank gangrene, particularly of the toes, heels, and lateral malleoli, suggests extensive disease....” (Merck Manual for Geriatrics, Section 11, Chapter 93)

Unfortunately, like its predecessor, the instructions for MDS 3.0 (Minimum Data Set) direct facilities to identify all skin ulcers as either pressure or non-pressure ulcers, including those that are due to mixed etiologies and/or end-of-life organ failures. However, Chapter 3, Section ‘M’ of the Resident Assessment Instrument (RAI) manual confirms that, “It is imperative to determine the etiology of all wounds and lesions.” To reduce liability, non-MDS records should document the multiple factors that caused each ulcer. In addition, nurses, wound care consultants and physicians should document when they educate the resident (family) to keep them fully informed about the multiple causes of skin ulcers, as well as the reasons why they may not heal.

Pressure ulcers are also commonly categorized by their “stage,” another example of the power our terms wield. However, the National and European Pressure Ulcer Advisory Panels recently suggested that clinicians consider replacing the term “stage” with “category” to better communicate the extent of tissue damage due to pressure ulcers. “Stage” implies that all pressure ulcers progress and resolve through stages: I, II, III and IV. They do not. “Category” is a less-hierarchical, more neutral term that avoids the mistaken belief of staged progression and resolution. Ulcers and wounds that are not caused by pressure, such as vascular ulcers and surgical wounds, should not be staged.

OTHER FACTORS TO RECONSIDER

Professionals should think about substituting “predictive factors” for “risk factors” when assessing residents for the possibility of skin breakdown and other unwelcome outcomes, such as falls with injury. Although subtle, this change in terms fully informs residents, families and staff that the resident’s underlying condition “predicts” that a pressure ulcer or a fall-related injury may occur. Appropriate care interventions help to reduce or delay the likelihood of predictable, unwelcome outcomes that are the consequence of advanced age, lifelong unhealthy habits, disease and impaired functional abilities.

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