Documentation

WoundSource Practice Accelerator's picture

Patients with wounds are cared for according to the scope and standards of practice, which are used to guide nurses and other members of the interprofessional wound care team. An intricate network of physicians, medical researchers, government regulators, and medical journal contributors helps develop the standard of care. Standards are not enacted like laws; rather, they arise naturally as a result of research investigations, existing physician practices, and technological advancements. Standard of care in the health care profession is sensitive to time, place, and person. The wound care standard must be carried out in accordance with accepted wound treatment standards that are evidence based.

WoundSource Practice Accelerator's picture

Wound documentation is critical for the delivery of effective wound care, the facilitation of care continuity, and proper health data coding. Inaccurate wound documentation can impact the ability to determine the best wound treatment options and the overall wound healing process. Unfortunately, almost half of all medical record notes on wounds lack key details on assessment and intervention in some settings.

WoundSource Practice Accelerator's picture

By equipping nurses with the tools necessary to document wounds quickly and accurately, care can be prioritized more effectively. The equal standard of care is maintained from admission to discharge. This continuity is especially important during times of the pandemic where we have experienced increases in nursing shortages and traveling nurses moving among hospitals. What has become even more critical is the requirement for a systematic approach to wound management.

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Kari K. Harman's picture

By Kari K. Harman, RN-C, CCM, CWCA, WCN-C, CSWD-C, ACCWS, DAPWCA

For patients discharged from the acute care setting, the road home can be laden with potholes and speed bumps. For many patients, the fear of the unknown after being newly diagnosed with a wound or the exacerbation of a health condition can be overwhelming. Caregivers are likely to have the same feelings as patients. This blog will navigate through some avoidable roadblocks and barriers to ensure a smooth ride home. By establishing manageable expectations and partnering with home health agencies that have proficient wound care programs, the patient and caregiver can genuinely be on the road to recovery.