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Ask the treatment expert
What should wound documentation include to support appropriate care?

Last month, we discussed the key components required for documentation of the clinical and physical characteristics of a wound. This second part presents the key components required for documentation of wound-care management interventions:

Treatment – Note current topical treatments and frequency of treatment.

Response to treatment – Is wound better or not? Indicate modifications to treatment plan and patient adherence to care plan.

Interventions – Document use of dietary supplements, lab tests, repositioning schedule, support surfaces, heel protection, skin barriers, and other interventions.

Referrals – These include dietary staff, clinical nurse specialists, physical therapists, surgeons, wound specialists and dentists.

Response to any procedure should include: what, when, who and how the procedure was performed and how it was tolerated.

Adverse reactions to care provided should include: communication with physician, interventions implemented to change treatment, and family/resident notification.

Monitoring – All wounds should be monitored daily with documentation of findings. Every instance of resident non-adherence with care plan and counseling efforts – should be well-documented in the resident's medical record.

Document any discussion of questionable medical orders, and the directions the doctor gave. Include the time and date of discussion and your actions as a result of the discussion and consequent directions given.
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