Ask the Treatment Expert about ... improve wound documentation

Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC
Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC

With regulators getting stickier, how can my facility improve wound documentation?

Information sharing is essential to promote quality wound care. Although there are no national, state or local regulations related to wound care documentation, individual skilled nursing facilities must have well thought-out and written policies and procedures. 

Providers must offer staff training, staff understanding, periodic competency evaluation and quality assessments with retraining if goals are not met.

Wound care documentation requires detailed information and is time-intensive. It must be timely and accurate, and follow the facility's policy and procedure. 

It is a communication tool used by the entire treatment team. Documentation is used to indicate exactly what has not worked in the past. 

Quality of care also is determined by the facts written in the medical record. Even if excellent quality of care is delivered, if it is not documented — or not provided based on the policy and procedures of the facility — the quality of the care will be diminished. 

Focus areas for documentation include:

• Comprehensive and thorough: Always document — date and time.

• Precise and accurate: Measure all wound dimensions in centimeters.

• Objective and factual: Document who, what, when, where, why and how.

• Legibility of documentation: It's a waste if no one can read what you wrote.

• Abbreviations: Use only the approved.

• Timely documentation: Document before you complete the resident encounter.

• Truthfulness: Facts are the facts.

• Caution: Do not assign blame.

Sharing accurate, comprehensive, factual, objective, legible, timely and precise wound documentation will provide the best quality wound care and will help avoid litigation.