Wound Documentation

Heidi Cross's picture
Risk Factors for Unavoidable Ulcers

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

According to the Agency for Healthcare Research and Quality, more than 17,000 lawsuits related to pressure ulcers (PUs) are filed annually in the United States, second only to wrongful death lawsuits. One of the greatest gifts to defense attorneys was when the Centers for Medicare & Medicaid Services (CMS) published F-Tag 314, finally acknowledging that some ulcers can occur despite best care. The facility essentially can maintain, “Hey, we did everything we were supposed to, and despite that, the patient developed that pressure ulcer”—that is, the ulcer was unavoidable. To prove unavoidability, proper documentation (proof) of best care needs to be in place, as well as documentation that all proper prevention and treatment measures were implemented.

Heidi Cross's picture
Turning and Positioning

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

Failure to T&P (turn and position) is always part and parcel of a pressure ulcer lawsuit and a key element of a complaint related to pressure ulcers, as illustrated in the opening quotation. T&P documentation is a dominant focus in chart analysis and is usually one of the first things that an attorney and the expert witness look for. If T&P documentation is satisfactory, the defendant is likely to prevail; if not, then the plaintiff may have a pretty rock-solid case. But as I have opined in previous blogs, is there such a thing as perfect documentation? Alas...NO! (Or at least, rarely.)

Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.

Jeffrey M. Levine's picture

by Jeffrey Levine MD

Pressure injury prevention and management are sometimes overlooked in the hospital setting, where the focus is generally on acute illness. Given the immense implications in terms of cost, complications, reputation, and risk management, it is in the interest of all facilities to maximize quality of care with regard to wounds. This post will offer some suggestions on how this can be accomplished in hospitals by tweaking the system for maximum quality.

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!

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.