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.
From the August 01, 2008 Issue of McKnight's Long-Term Care News
