Pressure Injuries

Cheryl Carver's picture
Case Scenarios: Wound Documentation

By Cheryl Carver, LPN, WCC, CWCA, CWCP, DAPWCA, FACCWS, CLTC – Wound Educator

Auditing documentation has always been part of my wound nurse role in some way or another. My first experience with auditing documentation with a fine-tooth comb was while working in the hospital wound center setting as a hyperbaric oxygen technician. Back then, hyperbaric oxygen therapy was more difficult to get reimbursed, and there were a lot of Medicare appeals. I would search through stacks of documentation to find validation for the diagnosis specific to the hyperbaric oxygen therapy indication. I quickly found out how ONE word determined reimbursement, and we are not talking pennies. The documentation is either there or it isn’t. Wound care documentation also requires the same impeccable documentation. Reimbursement is driven by Centers for Medicare & Medicaid Services (CMS) guidelines. We must follow the rules, or we do not get paid.

Heidi Cross's picture
Risk Assessment

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

When looking at medical charts from a legal perspective, one of the areas closely scrutinized is the risk assessment for skin breakdown and pressure ulcer development. Completing a risk assessment is considered a standard of care. Was the patient adequately assessed, and was this done in a timely fashion? Was it repeated at regular intervals, with a change in condition, or on readmission? Do scores seem appropriate for the patient's condition? Is there consistency among health practitioners? Were the results used to institute evidence-based and appropriate prevention and treatment measures and care plans? Or do the results seem to simply languish in the chart? What are the standards of care related to this?

Holly Hovan's picture
Pressure Injury Prevention

By Holly M. Hovan MSN, APRN, ACNS-BC, CWOCN-AP

What does your facility do to raise awareness regarding pressure injury prevention? We have lots of educational opportunities throughout the year, but one of our most important and prepared for days is the third Thursday in November – World Wide Pressure Injury Prevention Day! This is a day to raise awareness that has been promoted by the National Pressure Ulcer Advisory Panel (NPUAP). Every year, the NPUAP puts out a press release and lots of good information in terms of ways to educate and engage staff on such an important topic, on a national level.

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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.)

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Margaret Heale's picture
Details

By Margaret Heale, RN, MSc, CWOCN

In our point, click, fill-in-the -blanks world of ever increasing wound care algorithms and MOs, I have an ax to grind (straight into my so-called smart phone if I had the courage).

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Cheryl Carver's picture
Terminology

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

It is 2018, and health care professionals around the world are still debating what to call skin damage. I totally immersed myself in wound care because of losing my 47-year-old mother to what was then called "decubitus ulcers." I was young when my mother died, and I wanted to know why and how this could happen. My perspective is different from that of most clinicians because of my personal experience.

WoundSource Practice Accelerator's picture
Palliative Care

by the WoundSource Editors

Palliative care and hospice care are not the same, but they both share one goal. They both focus on a patient's physical, mental, social, and spiritual needs. Palliative care can begin at diagnosis and treatment or for patients at any stage of their illness. Patients may not want to receive aggressive treatment of non-healing wounds because of underlying diseases, pain, and/or cost.

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