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.