Professional Practice, Legal, and Regulatory Issues
Scope, delegation, and standards
Practice within your state nurse practice act and facility policy. Components of the nursing process, including assessment, staging, planning, and evaluation, are not delegable; unlicensed assistive personnel may perform tasks such as repositioning, hygiene, and skin observation with reporting. The legal standard of care is defined by clinical guidelines (for example, pressure injury prevention and treatment guidelines), facility policy, and what a reasonable clinician with similar training would do.
Documentation that protects
Chart objectively, measurably, and contemporaneously: dimensions and tissue percentages rather than "wound looks bad." Record assessments, interventions, the patient's response, education, provider notifications, and refusals. Never alter a record after the fact; corrections are made with a single line, initials, and date, and late entries are labeled as late. Chart only what you personally did or observed, and never document care that was not delivered.
Consent, privacy, and reporting
Obtain informed consent for procedures such as sharp debridement. HIPAA governs photographs and discussions of care; share information only with the patient or an authorized representative. Follow state mandates for reporting abuse, neglect, and mistreatment.
Quality and payment context
Pressure injuries are a nurse-sensitive quality indicator and are publicly reported. Hospital-acquired Stage 3 and Stage 4 pressure injuries are treated as hospital-acquired conditions for payment purposes, which makes accurate staging and documentation consequential. Incident reports go to risk management and do not replace factual charting in the medical record.
Traps and a rule of thumb
Watch for questions that reward charting opinions, charting by hindsight, or documenting a refusal without noting that education and alternatives were offered. Rule of thumb: if a specific, measurable observation is not in the record, it is treated as not having been done.