Wounds, including chronic and complex wounds, represent a tremendous challenge to the US health care system.1 In the United States alone, chronic wounds impact approximately 6.5 million patients, and the treatment of these wounds is estimated to cost $25 billion per year.2 Trauma, burns, skin cancers, infections, or underlying conditions, such as diabetes, can all contribute to a wound’s development and course. If one looks at the structure of wound terminology, they could ascertain that wound care is usually considered comorbid, defined by terms like diabetic foot ulcer, venous leg ulcer, and pressure injury.3
Proper wound management starts with thorough assessment and documentation, which can improve communication regarding care delivery across the multidisciplinary team. Inaccurate or incomplete documentation may affect the creation of the patient’s care plan and the healing process.2 Unfortunately, evidence-based wound care and assessment is, at times, left out in documentation. One study from 2015 found that 12% of wounds had no recorded diagnosis, and 56% of wounds documented as leg ulcers lacked a differential diagnosis.4 A failure to have proper wound documentation can jeopardize the healing trajectory. In fact, without the differential diagnosis for a leg ulcer, a multidisciplinary team member may unintentionally prescribe or apply a potentially detrimental treatment, like compression therapy, to treat an arterial ulcer.
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In addition to circumventing avoidable errors, documentation should note institutional, clinical practice, and regulatory guidelines. Multiple lists are available that address comprehensive wound documentation, and the list below outlines key components of an initial evaluation to be documented in the medical record.1These items include the following1-2:
With so many factors contributing to wound healing, knowing which items to document can be difficult. However, it can be helpful to also consider some other factors that can be included in documentation. For instance, a patient’s responsiveness to a particular treatment, changes in the treatment (or reasons for not changing it), referrals, refusal of care, or even resident or caregiver information can be documented, too.6 This list provides a starting point to ensure wound documentation is sufficient to support ongoing care and transitions in care.
Proper documentation can ensure continuity in care and that all regulatory requirements are met. Most importantly, analogous documentation can improve patient care and outcomes by making available key patient information to members across the multidisciplinary team.
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.