OBJECTIVE: Our objective was to describe the spectrum and preferences of terminology used by house staff and attending physicians in internal medicine, general surgery, surgical subspecialties, physical medicine and rehabilitation, staff nurses, clinical nurse specialists, and others when documenting a skin ulcer examination on admission or at consultation. DESIGN: This study was a retrospective review of a purposeful sample of 75 charts. SETTING AND SUBJECTS: Study subjects were physicians and nurses working in an urban teaching hospital. METHODS: Methods used were abstraction from the medical record of the frequency with which aspects of a skin ulcer examination were documented and qualitative analysis of the descriptive terminology. RESULTS: As consultants, clinical nurse specialists for skin care and plastic surgeons were the most complete in documenting location, size, and the tissue characteristics of skin ulcers. Ninety percent of house staff and staff nurses of the primary team documented the existence and location of the ulcer. Some characteristic of the tissue was described by staff nurses and house staff for 80% and 78% of the ulcers, respectively. Quantitative size was the least frequently documented component by both nurses and house staff for 60% and 33% of the ulcers, respectively. A total of 66 unique terms including 38 nonmedical, nonspecific, or ambiguous terms were found. CONCLUSIONS: Documentation of skin ulcers in the notes of physicians and nurses are incomplete and nonstandardized, and the terminology used does not allow an accurate retrospective conceptualization of the ulcer. The clinical implications are miscommunication between multidisciplinary teams, difficulty assessing healing rates, and inability to perform retrospective quality assurance reviews. Development of a standardized skin ulcer examination with a meaningful taxonomy of terms acceptable to physicians, nurses, and occupational and physical therapists is needed to teach interdisciplinary care of patients with skin ulcers.
OBJECTIVE: Our objective was to describe the spectrum and preferences of terminology used by house staff and attending physicians in internal medicine, general surgery, surgical subspecialties, physical medicine and rehabilitation, staff nurses, clinical nurse specialists, and others when documenting a skin ulcer examination on admission or at consultation. DESIGN: This study was a retrospective review of a purposeful sample of 75 charts. SETTING AND SUBJECTS: Study subjects were physicians and nurses working in an urban teaching hospital. METHODS: Methods used were abstraction from the medical record of the frequency with which aspects of a skin ulcer examination were documented and qualitative analysis of the descriptive terminology. RESULTS: As consultants, clinical nurse specialists for skin care and plastic surgeons were the most complete in documenting location, size, and the tissue characteristics of skin ulcers. Ninety percent of house staff and staff nurses of the primary team documented the existence and location of the ulcer. Some characteristic of the tissue was described by staff nurses and house staff for 80% and 78% of the ulcers, respectively. Quantitative size was the least frequently documented component by both nurses and house staff for 60% and 33% of the ulcers, respectively. A total of 66 unique terms including 38 nonmedical, nonspecific, or ambiguous terms were found. CONCLUSIONS: Documentation of skin ulcers in the notes of physicians and nurses are incomplete and nonstandardized, and the terminology used does not allow an accurate retrospective conceptualization of the ulcer. The clinical implications are miscommunication between multidisciplinary teams, difficulty assessing healing rates, and inability to perform retrospective quality assurance reviews. Development of a standardized skin ulcer examination with a meaningful taxonomy of terms acceptable to physicians, nurses, and occupational and physical therapists is needed to teach interdisciplinary care of patients with skin ulcers.