Wound Documentation Standards to Follow to Help Avoid Legal Issues

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by Aletha Tippett MD

Medical providers, and especially wound care providers, seem to always be under the looming shadow of lawsuits and legal issues. I have read lots of charts for legal reviews and it actually is very straightforward to avoid or mitigate any legal problems.

What You Need to Document for Your Wound Care Patients

  1. If you have a wound protocol, follow it or document why you didn't. For example, if your protocol says a bed or chair bound patient on admission is high risk, then treat them as high risk, or document why you didn't.
  2. If you use an assessment tool such as Braden or Norton, be sure you know how to use it properly, and use it per protocol.
  3. Document all calls to a physician and the response.
  4. If there is a physician order, follow it and document that you did. For example, if an order says to notify the physician if there is blood in the urine and you see blood in the Foley catheter, notify the physician and document that you did notify them and what the response was.
  5. If you notice a change in your patient, report it to the proper person. For example, you might notice that the patient has stopped eating normally, or the patient is acting differently. In an elderly patient this could be the first sign of infection.
  6. If you find an alteration in the skin, record it and report it per your protocol. Document this with an accurate description—where on the body is the alteration, how big is it, what does the tissue look like, how did it get there?
  7. Document when you reposition or turn your patient and if not, why not. Just an aside here, be careful if your protocol states to turn every 2 hours; if you have not documented q 2 hr turning that will be a problem with the lawyers and the surveyors.
  8. Document any discussions you have with your patient or caregiver about risks and benefits of their care. For example: your patient insists on sitting in their wheelchair and going to the smoking room for long periods of time, or out of the facility all day. You should document a discussion about risk of pressure ulcers. If your patient has a wound, document your discussions with the patient or caregiver about their wound care.
  9. Please do a complete skin exam on admission and document any concerns of deep tissue injury. Learn how to recognize possible deep tissue injury: this could be a bruise, or a soft or tender spot, or just discoloration.

If you follow the rules and the standards we uphold,
a. you will give your patient good care, and
b. you will stay out of legal trouble.

If you are sued, your defense will be strong if you have taken proper care and your wound documentation supports you. If you haven't done what needs to be done – or haven't documented it – then you will have no defense or a weak one at best. As an expert witness there are defense cases I will not take because the defense is very poor or absent. Likewise, there are plaintiff cases I will not take because the defense is too strong. Rarely is the lawsuit about what kind of care was given to a wound. For the lawyers, it almost always is about not following standards, or not documenting properly. For the patient who sued, it usually is because no one talked to them about their wound.

About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


We have an interest in wound care basics that include appropriate documentation.

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