Wound Documentation

Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Scope of Practice and Standards of Practice guide nurses and other members of the interprofessional wound care team in caring for patients with wounds. Documentation in the medical record is a key aspect of the standard of practice and serves to record the care delivered to the patient or resident. Your documentation should follow your facility guideline for documentation. Accurate documentation helps to improve patient safety, outcomes, and quality of care.

This WoundSource Trending Topic blog considers general wound documentation dos and don'ts and presents 10 tips for success. Good, better, and best documentation examples are included for each tip.

Heidi Cross's picture

By Heidi Cross, MSN, RN, FNP-BC, CWON

In the previous blog, I briefly went through the standards of care when it comes to nutrition and pressure injury (PI) prevention and development and discussed what a large role nutrition plays in PI litigation. Here are several instances: Punitive damages of $92 million, later lowered to $11,855,000, were imposed where malnutrition and dehydration were proven against a nursing home. A dietary manager for a nursing home told state surveyors that her nursing home had "dropped the ball" on a resident's nutrition needs when that resident had lost 17 pounds in 75 days; a $1,385,000 settlement was reached. Malnutrition with a loss of 27% of body weight in 15 months led to a $380,000 settlement just before trial. Shocking, isn't it? It literally "pays" to pay attention to nutrition standards of care.

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Telehealth

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

Wound care has evolved into a massive specialty service in the past few decades, with new treatment modalities, advances in care, and thousands of wound care products. On the forefront of advancements in technology and wound care is a new way to provide care to the patient: telehealth.

Diane Krasner's picture
Wound Care Lawsuits

By Diane L. Krasner, PhD, RN, FAAN

Originally a poster first conceived in 2009, "Six Sticky Wickets That Commonly Occur in Wound Care Lawsuits" is as relevant today as it was a decade ago. In my review of wound care medical malpractice cases, I see these six difficult situations ("sticky wickets") occurring all too often. Strategies for avoiding the Six Sticky Wickets have been updated and are discussed here.

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Temple University School of Podiatric Medicine Journal Club

By Temple University School of Podiatric Medicine Journal Review Club

The advancement of technology and the introduction of the World Wide Web have allowed information to be a click of a button away for health care providers as well as patients. This advancement led to the demand and production of portal devices such as smartphones, which transformed many aspects of society today, including health care. Today, smartphone applications may aid health care providers in drug reference, diagnosis, treatment, literature search, and even medical training. In 2009, an estimated 6.5 million patients had chronic wounds and spent more than $25 billion dollars on wound care. In addition, rising costs of wound management have suggested the need for the use of mobile applications in treatment of wound care patients.

Holly Hovan's picture
Wound Documentation Mistakes

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

Documentation is a huge part of our practice as wound care nurses. It is how we take credit for the care we provide to our patients and how we explain things so that other providers can understand what is going on with the patient, and it is used for legal and billing purposes as well.

Heidi Cross's picture
End of Life Skin

By Heidi Cross, MSN, RN, FNP-BC, CWON

Ms. EB, a frail 82-year-old woman admitted to a long-term care facility, had a complex medical history that included diabetes, extensive heart disease, ischemic strokes with left-sided weakness and dysphagia, dementia, kidney disease, anemia, chronic Clostridium difficile infection, and obesity. Her condition was guarded at best on admission, and she had a feeding tube for nutrition secondary to dysphagia. Despite these challenges, she survived two years at the facility.

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Risk Assessment Standardization

By the WoundSource Editors

The prevalence of pressure injuries among certain high-risk patient populations has made pressure injury risk assessment a standard of care. When utilized on a regular basis, standardized assessment tools, along with consistent documentation, increase accuracy of pressure injury risk assessment, subsequently improving patient outcomes. Conversely, inconsistent and non-standardized assessment and poor documentation can contribute to negative patient outcomes, denial of reimbursement, and possibly wound-related litigation.

Kelly Byrd-Jenkins's picture
Pressure Ulcer Reduction in Acute Care

by Kelly Byrd-Jenkins, CWS

It may come as no surprise to some, but pressure ulcers are among the only hospital-acquired conditions that have been on the rise in recent years. Other hospital-acquired conditions—such as adverse drug events, falls, and catheter-associated urinary tract infections—have decreased, according to a statement by the Agency for Healthcare Research and Quality in January of this year.

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Heidi Cross's picture
Unavoidable Pressure Ulcers

By Heidi Cross, MSN, RN, FNP-BC, CWON

"At all times material hereto, defendant failed to develop an adequate care plan and properly monitor and supervise the care and treatment in order to prevent her from suffering the development and deterioration of bed sores."