Wound Assessment and Documentation

Cheryl Carver's picture
safety net

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

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

Aletha Tippett MD's picture
periphereal vascular disease

By Aletha Tippett MD

I was recently talking to a young nursing student who told me she had had a terrible week and cried when she had to do wound care for a patient. When asked what the problem was she reported that her patient was an elderly man near death who had severe peripheral vascular disease with gangrene on both feet. He had severe pain whenever touched and she was instructed to wrap his legs with gauze and ace wraps.

Cheryl Carver's picture

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

Being an independent wound care education consultant in long-term care, I get a lot of questions regarding moisture-associated skin damage (MASD). Is it MASD or a pressure ulcer? When do I change it from MASD to pressure ulcer in my documentation?

Lydia Corum's picture
black widow spider

By Lydia A. Meyers RN, MSN, CWCN

In the times that I have worked with amazing hospitals and doctors, I have learned and gathered information on the differences between two types of necrotizing infections that happen in the world of wound care. Necrotizing fasciitis (NF) and spider bites can present as similar in nature and need immediate intervention.

Samantha Kuplicki's picture
Pain

By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWS, CWCN, CFCN

The Patient Assessment
You've been asked to evaluate a patient for negative pressure wound therapy (NPWT). It turns out they're a perfect candidate, so you start the process to have the unit placed immediately! The order is entered into the EHR for the recommended settings, and the initial dressing application is scheduled.

Aletha Tippett MD's picture
Braden Scale

By Aletha Tippett MD

I was recently asked to speak on best practices for prevention of pressure ulcers for a group of state surveyors. This is an excellent subject and here is how I would address it:

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 pressure ulcers and weight loss.

WoundSource Editors's picture
Image from the National Cancer Institute

By the WoundSource Editors

A myriad of factors need to be addressed when evaluating a patient with a wound. A thorough patient history, including previous wounds, surgeries, hospitalizations, and past and existing conditions will help guide your clinical assessment, in addition to a number of questions specific to the wound(s) being assessed. Following is a list of general questions to ask when evaluating a wound care patient. (Please note that this list is not comprehensive and is intended only to serve as a guide):

Janis Harrison's picture

By Janis E. Harrison, RN, BSN, CWOCN, CFCN

As I was pushed from the room where my husband was coding, I was met by a tiny little nun, we'll call Sister. She tried to move me to a waiting area nearby but I knew I was not going to step away from the door. They had not listened to or assessed my husband during a very concerning time and he was supposed to be in post-op recovery.

Laurie Swezey's picture
Tunneling Wound

By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

As part of a thorough wound assessment, in addition to noting location and measuring size, the entire wound bed should be probed for the presence of tunneling and/or undermining. If you are unsure what tunneling and undermining are and how to recognize these phenomena, here's an explanation of these terms and how to assess wounds for their presence.