Wound Documentation

Cheryl Carver's picture
Documentation Error

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

Most of my experience has been in the hospital wound center setting. However, in the last five years you could say I was converted into the long-term care arena, where I felt I could help most from an education and documentation standpoint. I have trained many physicians on how to best document inside the long-term care setting, because of the federal guidelines and annual surveys. Documentation in long-term care is substantially different from documentation in the hospital, and providers have a higher liability in this setting, given all the wound-related lawsuits. However, the documentation discrepancies can vary. I have given you a few case scenarios in this blog to help define consistent documentation.

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Margaret Heale's picture
Standardized Documentation

by Margaret Heale RN, MSc, CWOCN

Wound care can be so straightforward. The process starts with a comprehensive assessment, and then the wound care regimen can be planned and the frequency of dressing changes determined.

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Aletha Tippett MD's picture
wound care and legal issues

by Aletha Tippett MD

Medical providers, and especially wound care providers, seem to always be under the looming shadow of lawsuits and legal issues. I have written about this before, but it continues to be an issue as I receive requests for legal reviews repeatedly. I have read many charts for legal reviews, and it actually is very straightforward to avoid or mitigate any legal problems.

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Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.

Cheryl Carver's picture


Incorrect staging of pressure injuries can cause many types of repercussions. Incorrect documentation can also be worse than no documentation. Pressure injuries and staging mistakes are avoidable, so educating clinicians how to stage with confidence is the goal.

Tissue Analytics's picture
big data analysis for wound treatment

by Matthew Regulski, DPM

One of the most difficult challenges in wound care today is deciding exactly which treatments to use. Due to the high inaccuracy of wound evaluation techniques, specifically ruler measurements, it is extremely difficult to quantify changes in a wound's progress. In addition to the lack of an accurate and objective quality metric for evaluating wounds, modern electronic health records are simply not built to handle analysis of data

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Terri Kolenich's picture
long-term care facility pressure injury staging at admission

by Terri Kolenich, RN, CWCA, AAPWCA

Question: What are Quality Measures, how does my long-term care facility measure up, and how can we improve?

Answer: Proper pressure injury staging on admission, that's how!

Terri Kolenich's picture
compliant pressure ulcer documentation

by Terri Kolenich, RN, CWCA, AAPWCA

It has been a long week. The CMS state survey team entered your facility Sunday afternoon at 2pm. Thursday is finally here and the state survey exit meeting is only minutes away. Your heart is heavy and your mind is occupied with thoughts of an in-house acquired stage IV pressure ulcer. The surveyor observed your dressing change and reviewed every bit of documentation pertaining to this stage IV pressure ulcer. The burning in your gut has completely convinced your brain that your facility will receive the dreaded F-Tag 314 because of this in-house acquired pressure ulcer.

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Cheryl Carver's picture
eschar on heel pressure ulcer


Knowing the difference between a scab and eschar may not seem like a big deal. However, if you are being audited, or your facility is in survey, you might think otherwise. Here are a couple of scenarios for you to think about.

Rick Hall's picture
documenting wounds

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 documentation, you could end up in a LAWSUIT.