Wound Documentation

By the WoundSource Editors Writing up a case report is an important professional activity in not only wound care, but in any other field as well. A case report records the details of the presentation of signs and symptoms, assessment, diagnosis, treatment and outcomes of a patient case or series of cases. Case reports typically describe an unusual presentation or complication relating to the patient's condition, or a new clinical approach to a common problem. The publication of a case report in a peer-reviewed journal, if that is your intent, is a great addition to your CV, especially if you are new to the profession.

By the WoundSource Editors A myriad of factors need to be addressed when evaluating a patient with a wound. A thorough patient history, including previous wounds, surgeries, hospitalizations, and past and existing conditions will help guide your clinical assessment, in addition to a number of questions specific to the wound(s) being assessed. Following is a list of general questions to ask when evaluating a wound care patient. (Please note that this list is not comprehensive and is intended only to serve as a guide):

By Rick Hall, BA, RN, CWON 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.

By Margaret Heale, RN, MSc, CWOCN Most of the residents here are elderly, though some of the more acute rehab patients are quite a bit younger than me. We actually have five women over a 100 out of 116 people, quite impressive with the eldest being 105 years old. As for me, I am a retired British matron just doing a little volunteer work near where my granddaughter works.

By Kathy Gallagher, DNP, APRN-FNP, CMC, UMC, BC, WCC, CWS, FACCWS Welcome to the first in a series of blogs focusing on acute surgical wound management. Future segments will discuss steps toward developing an acute surgical wound service (ASWS) and tips reflective of successful healing strategies.

By Lindsay D. Andronaco RN, BSN, CWCN, WOC, DAPWCA, FAACWS Patient safety is always of the utmost importance. Health care providers aim to improve the health of others. Having been in many settings during my career, I have been privileged to see the transition of how nursing has changed due to technological advances. Long gone are the days sitting in rural Vermont trying to decipher handwritten orders, counting drips on a dial control IV set and doing pediatric drug calculations while a parent hovers over you. Luckily, we have made strides to eliminate such frustrations, ways of frequent error, and time consuming tasks. Nursing has been forced to evolve as technology evolves.

By Karen Zulkowski DNS, RN, CWS How many of you know how knowledgeable you are about wounds? Keeping up with the latest articles and treatments is difficult. This is especially true for a staff nurse that only encounters patient wounds occasionally. Larger facilities and home health agencies have wound nurses, but smaller facilities do not. Pressure ulcer knowledge has been examined for Registered Nurses across the United States using the Pieper Pressure Ulcer Knowledge Test. When urban versus rural nurses' knowledge was examined between rural Montana nurses and urban New York City nurses all scored at a "C" level. Similar testing at a Florida VA found nurses score 77% and only improved to 81% after education programs. Registered nurses that participated in the New Jersey Hospital Association pressure ulcer collaborative scored slightly higher on the Pressure Ulcer Knowledge test at 83%. However, percent correct is still a "B-" average. Certified wound care nurses scored at 93%.

In this interview, Dr. Jonathon Johnson, MD, MBA, CWSP covers the basics of coding for CTP reimbursement, such as JC and JW modifiers and how they are used.

by the WoundSource Editors Advancements in molecular microbiology, microscopy technology, and techniques for study of bacteria have increased the ability to identify the existence of biofilms, but there still remains the unknown, such as differentiating between planktonic bacteria and biofilm.1 Chronic non-healing wounds harbor bacteria across the wound etiology classification.2–4 Malone et al. determined that the prevalence of biofilms in chronic wounds was 78.2% (confidence interval, 61.6–89, P < 0.002).2 The development of biofilms moves through a common pattern: attachment, microcolony formation, maturation, and dispersion. The initial attachment is reversible, but the attachment becomes stronger as cells multiply and change their gene expressions. This cell communication process is referred to as quorum sensing, allowing cells to survive.