Skip to main content

5 Tips for Proper Wound Care Documentation

Rick Hall, BA, RN, CWCN
February 25, 2016

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 wound care documentation, you could end up in a LAWSUIT. With some patients, families and attorneys looking for a way to attain capital gain, we health care providers must protect ourselves and the facilities we work for.

Essential Wound Care Documentation Practices

  1. Upon admission, a full body inspection of the patient must be performed and any pressure ulcers photographed, measured and documented including any red areas which are non-blanchable. Documentation of existing pressure ulcers and skin areas showing signs of damage is important because if in 3 to 5 days it worsens and you didn't document it, you have caused your facility a deficiency.
  2. If you have a patient who leaves the floor or facility temporarily and they develop a pressure ulcer within 72 hours after returning, you can look back and determine where they acquired that pressure ulcer. So document where they were 72 hours ago. The deficiency belongs there.
  3. Lawyers and their hired medical personnel are also looking for key words in the charting like "packed the wound." Remove the terms "pack" or "packed" a wound from your documentation language. If the wound gets worse, you could find yourself defending the wording used in your wound documentation. If you packed a wound and it got worse, then that could be interpreted as you "packed" it too tight and caused the damage. Choose language such as "filled the wound loosely," or "laid the dressing in the wound bed" to document your wound treatment.
  4. When measuring a wound, measure from head to toe for length (0600 and 1200), and 0300 to 0900 for width. This is the way most wounds are measured and you will have more consistent measurements using this method. Make sure all those in your facility who measure and document wounds are consistent with whatever wound measurement method your facility protocol dictates.
  5. Use measurement numbers instead of approximate sizes such as that of a dime, nickel, quarter or half dollar size. Lawsuits have been lost using this type of description of a wound.

Management and Documentation of End Of Life Wounds

With End Of Life (EOL) wounds, more careful documentation is necessary. The National Pressure Ulcer Advisory Panel has provided in their Quick Reference Guide under Pressure Redistribution a number of guidelines that include turning and repositioning individuals based on his or her wishes, and as tolerated at periodic intervals. Comfort of individuals with EOL wounds is of great importance. Flexible repositioning schedules should be established based on the individual's preferences and tolerance, along with factoring in support surface characteristics for redistributing pressure. Other guidelines for EOL wounds include pre-medicating individuals with significant pain on movement 20-30 minutes prior to his or her scheduled position change. Close observation of turning choice, including whether the individual has a "position of comfort" with an explanation of the basis for this positioning is also important to note.

In managing the EOL wounds of individuals who are actively dying or who have conditions which confine them to single position of comfort, delivering care that affords comfort may supersede pressure ulcer prevention measures. Clearly documenting the turning and repositioning of individuals with EOL wounds, including the rationale and factors impacting the decisions made for their care – including the factors addressed – is critical to providing comprehensive documentation. A phenomenal skin condition might occur during a person's end of life. This condition has been named "Kennedy Terminal Ulcer" (KTU). The etiology of the KTU is unknown and more research needs to be conducted to understand this condition (see my blog for more on the KTU). The KTU is a condition some people get when they are at the end of life. Not all individuals have these phenomena happen but when it does, it is devastating to all involved. It can happen even though everything was done to prevent pressure ulcers, including turning and repositioning, as well as use of a proper support surface which offloads pressure on the body.

Check labs and other documents as to other organs shutting down. Pre-albumin is important to check because albumin is what keeps the fluids in the vascular system. Usually the pre-albumin is below 10 and often 5 or less in individuals actively dying. As I recently discussed in my blog, I believe this condition to be lividity prior to death, not a pressure ulcer as we have named it. With a precedent now set by the state of Wisconsin, caregivers are also at risk for a lawsuit. Caregivers should document interventions they have done in the care given to their loved ones, which includes documenting assistance from an outside source. Include dates of contact, in addition to the source(s) of assistance and interventions performed.

About the Author

Rick Hall is a wound and ostomy educator and consultant for Kaiser Permanente. 

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