Wound Documentation

Cheryl Carver's picture
pressure-injuries

By Cheryl Carver LPN, WCC, CWCA, CWCP, FACCWS, DAPWCA, CLTC

Incorrect staging of pressure injuries can cause many types of repercussions. Incorrect documentation can also be worse than no documentation. Pressure injuries and staging mistakes are avoidable, so educating clinicians how to stage with confidence is the goal.

Terri Kolenich's picture
long-term care facility pressure injury staging at admission

by Terri Kolenich, RN, CWCA, AAPWCA

Question: What are Quality Measures, how does my long-term care facility measure up, and how can we improve?

Answer: Proper pressure injury staging on admission, that's how!

Terri Kolenich's picture
compliant pressure ulcer documentation

by Terri Kolenich, RN, CWCA, AAPWCA

It has been a long week. The CMS state survey team entered your facility Sunday afternoon at 2pm. Thursday is finally here and the state survey exit meeting is only minutes away. Your heart is heavy and your mind is occupied with thoughts of an in-house acquired stage IV pressure ulcer. The surveyor observed your dressing change and reviewed every bit of documentation pertaining to this stage IV pressure ulcer. The burning in your gut has completely convinced your brain that your facility will receive the dreaded F-Tag 314 because of this in-house acquired pressure ulcer.

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Cheryl Carver's picture
eschar on heel pressure ulcer

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Knowing the difference between a scab and eschar may not seem like a big deal. However, if you are being audited, or your facility is in survey, you might think otherwise. Here are a couple of scenarios for you to think about.

Rick Hall's picture
documenting wounds

by Rick Hall, BA, RN, CWON

Wound care documentation is a hot topic with overseeing agencies dealing with the medical industry. Good documentation is imperative to protect all those giving care to patients. Documentation should be Legible, Accurate, Whole, Substantiated, Unaltered, Intelligible and Timely. If these components are not incorporated into your documentation, you could end up in a LAWSUIT.

Cheryl Carver's picture
medical documentation

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

In my role as a consultant and educator, I thought it would be interesting to acquire a handful of perspectives from wound care providers who work in the long-term care arena, and explore their responses.

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Margaret Heale's picture
Accountability

by Margaret Heale, RN, MSc, CWOCN

Most of the residents here are elderly, though some of the more acute rehab patients are quite a bit younger than me. We actually have five women over a 100 out of 116 people, quite impressive with the eldest being 105 years old. As for me, I am a retired British matron just doing a little volunteer work near where my granddaughter works.

Mary Ellen Posthauer's picture
medical records

by Mary Ellen Posthauer RDN, CD, LD, FAND

As Dr. Aletha Tippett noted in her December blog, following wound documentation standards can help clinicians avoid legal issues. Pressure ulcer litigation often involves nutrition issues. Patients with chronic wounds frequently have unintended weight loss, dehydration and malnutrition. In long-term care facilities, the most prevalent types of alleged harm are falls, pressure ulcers, weight loss and dehydration. The odds of being sued are positively associated with pressure ulcers and weight loss.

WoundSource Editors's picture

by the WoundSource Editors

Litigation over hospital-acquired pressure ulcers represents a significant fraction of a medical malpractice attorney's caseload. The liability issues have shifted since October 1, 2008 when the Centers for Medicare and Medicaid Services and several private payers began denying reimbursement for care related to hospital-acquired stage III and IV pressure ulcer. Prior to October 2008, the experts battled over whether a pressure ulcer was avoidable. Now, they still do, but plaintiff attorneys and their experts can point to the government's stance that pressure ulcers are avoidable, "never events". Defense experts must assert that everything possible was done to avoid the ulcer, or it was not really caused by pressure.

Cheryl Carver's picture

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

As a traveling wound care educator for physicians, I am observing many changes within the state survey process for long-term care. Wound care physicians working in long-term care are feeling the same anxiety that facility leaders and staff members are, as the time nears the window for an annual state survey.