How to do it... Wound care documentation
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A key facet of successfully treating wounds is documenting them appropriately, particularly when it comes hard-to-heal areas. Experts advise here how to put yourself in position for good outcomes—and stay there—using these documentation and tracking tips.
Use an all-inclusive Centers for Medicare & Medicaid Services-compliant tool. That is one of the first things Diane Heasley, RN, CWCN, WCC, DAPWCA, CNS, vice president of clinical services for DermaRite Industries, recommends.“Have orders preprinted to include all modalities of care so that the nurses do not miss any issues for prevention or active treatment,” she adds.
There's nothing wrong with placing documentation prompts in various places, Heasley adds.“Have a documentation ‘cheat sheet' posted near documentation stations so that the clinician remembers all that is important to document,” she says.
In addition to having admission packs ready beforehand so no extra chasing of forms is needed, keep various other resources in a central location to deal with new developments.“Have an investigative protocol checklist to investigate new wounds which controls standards and does not allow deviation from CMS standards set forth on November 12, 2004,” Heasley says.
Perhaps most important of all, she emphasizes that there is no room for the opinions, “I believe,” “I think” or “It appears” in documentation of this type.
“We are there to assess and clearly report observation—not to diagnose,” Heasley concludes.“We must have the appropriate physician documentation from the MD to support vascular intention in a wound and unavoidability. They need to understand the skilled care constraints clearly to avoid harming a facility from a regulatory view.”
Keep extenuating factors in mind. “Documentation not only of the wound and treatment but of factors that may affect wound healing such as nutritional status, oxygen delivery to the tissue and even medications can affect the potential for actual healing,” notes Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC, vice president of clinical services for RecoverCare.
In addition, previous medical history and comorbidities need to be well documented, say Mark Richards, PT, MS, CEEAA, vice president of clinical education for Accelerated Care Plus, and Beth Sherman, PT, CWS, division vice president for the company.Factors to consider include conditions that might affect nutritional status/absorption of nutrients, circulatory/healing capacity, pulmonary/lung function and oxygenation, as well as immune system function, patient mobility, and medications that could alter a resident's capacity for healing.
Be sure to coordinate paperwork from a team approach to wound care, Richards and Sherman say.
“Speech, physical and occupational therapies should screen or evaluate any patients with wounds,” they say.
“Documentation of these referrals and subsequent consultation should be included. All should work from the same evaluation/values of wound assessments noted above as a cohesive, interdisciplinary team.”
Continuity is criticalin many aspects of wound care: “Wounds should be assessed by the same clinician as frequently as possible to enhance sensitivity of detecting healing or undesirable changes within the wound,” notes Stacey Scoggin Pugh, RN, senior director, global development, KCI Inc.Photographs of wound appearance over time also can assist caregivers' treatment and documentation efforts, she reminds.
Adds Sheila Cougras, director of quality for Net Health Systems: “You want to be able to have the ability within your documentation system to get a larger perspective, from above, to see what you've done for this patient, rather than just looking at the last treatment. See how you can change direction.”
Mistakes to avoid
-Merely assuming everyone on the care team knows documentation needs and protocols. Remind, remind, remind
-Using subjecting or opinionated language in assessments rather than sound, objective measures
-Neglecting to take other medical factors into account