Four eyes are better than two: Check out this proven method for wound assessment and documentation.

Two nurses reviewing a patient chart.
When it comes to the practice of wound care, it’s always good to know what other experts are talking about and implementing in their facilities. Take wound care specialist Kara Couch, the director of in-patient wound care at George Washington University Hospital. Kara chairs a monthly hospital acquired pressure injury committee and was instrumental in developing the hospital’s pressure injury prevention program.

Recently, Kara shared her expertise via a webinar entitled Building a Pressure Injury Program that Works. Her discussion includes valuable learnings, data and insights on reducing the occurrence of hospital acquired pressure injuries through proven methods of wound assessment and documentation.

One such method is the Four Eyes Skin Assessment, which is a simple, but effective way to assure consistency and accuracy when it comes to evaluating pressure injuries. This article details how that assessment works and why it’s essential to a successful pressure injury prevention program.

What is the Four Eyes Skin Assessment?

It’s all in the name. This collaborative method utilizes two different nurses (two sets of eyes = four eyes) to identify and record pressure injuries within four hours of a patient’s admission, transfer, or if they’ve been off the floor for more than 4 hours. Both nurses inspect and assess each patient and then cosign electronic medical records (EMRs). It’s a quick, simple and effective way to document skin injuries and identify risk factors upon admission, but there are more benefits than just efficiency.

Benefits to the Four Eyes Assessment

  • Education to peers – When led by skin champions and supported by leadership, the Four Eyes Skin Assessment promotes an environment for education and training. Skin champions also serve as advocates for overall performance improvement, and help to motivate other nurses to take ownership and responsibility in helping to prevent pressure injuries. Better education leads to a more knowledgeable staff, which in turn can enable more informed and supported patient.
  • Reinforces best practices – By assuring accuracy and consistency, utilizing the four eyes assessment is a great way to institute best practices and drive a more cohesive approach to pressure injury prevention and treatment. Standardizing the method of documenting wounds provides a baseline to treat any identified injuries and better monitor them. According to Kara, “It really helps to make sure everyone is looking at the same thing, and it’s a great way to mentor newer nurses who are maybe unsure if they’re looking at the beginning of deep tissue skin damage. It really just enforces the same practices throughout your entire facility.”1 In addition to the identification of pressure injuries themselves, risk factors such as poor mobility or incontinence issues can also be more quickly identified and intervention can begin more efficiently.
  • Helps reduce the rate of hospital acquired pressure injuries – Studies show significant improvement in the reduction of hospital acquired pressure injuries, but also an increase in the number of pressure injuries identified on admission.

Case in point: when a 26-bed medical/surgical transplant unit at an 800 bed tertiary care academic medical center trialed the Four Eyes Assessment, it showed significant change in both the increase of identified pressure injuries on admission (7/month – 18/month on average) as well as a decrease in HAPI’s (5/month – 1/month on average). Outcomes were measured via documentation audits after a 6 month period.2

In addition to the identification of pressure injuries themselves, risk factors such low mobility, nutrition concerns, or incontinence issues can also be more quickly identified and intervention can begin more efficiently.

What to do when you’re not seeing eye-to-eye.

Despite the usefulness of having two sets of eyes to help investigate wounds, occasionally there may be disagreement on assessment. For example, what happens when a nurse stages a pressure injury on admission, but when the WOC nurse sees it and disagrees with that assessment? According to Couch, it’s best to coordinate and collaborate early on as to avoid any confusion later, but ultimately, “You would go with the expertise of the WOC nurse,” she says, “We ask that in real time the WOC nurse speaks to the bedside nurse and reviews the proper staging with them, so that moving forward, their documentation should match with the WOC nurse. Once the WOC nurse sees the patient, they’re going to keep seeing them, so you can look to those notes as expert guidance.”

For more insights from Kara Couch, MS, CRNP, CWCN-AP, view her webinar here: Building a Pressure Injury Program that Works 3.


  1. Couch, Kara. Building a Pressure Injury Prevention Program that Works. Webinar. 2019. https://www.medline.com/pages/pressure-injury-prevention-webinar/
  2. Salicki, Amanda, and Allyssa Dion. “Four Eyes within Four Hours: A Quality Improvement Project to Decrease Hospital Acquired Pressure Ulcers.” Hartford Hospital, 2016, hartfordhospital.org. https://hartfordhospital.org/File%20Library/CNRA/2016-poster-Four-Eyes-PU-assessment-Salicki.pdf
  3. https://www.medline.com/pages/pressure-injury-prevention-webinar/