In a recent survey of wound care professionals who work in nursing homes, almost half reported observing wound documentation that was inaccurate and led to adverse patient outcomes including sepsis, gangrene, prolonged pain, transfer to ICU, amputations and even death.

Study participants noted that the main causes of poor documentation are lack of wound knowledge and lack of attention to wounds. In addition, because wound performance in nursing homes is graded by state agencies and the Medicare administration, many nurses and doctors minimize the severity of wounds, which can result in ineffective treatment and painful outcomes for patients.

A lack of accurate wound documentation has real life implications. Take the following examples provided by the wound care professionals who participated in this study:

  • Patient A’s hip wound was diagnosed as superficial, but the wound was covered with leathery dead skin. Based on the wound documentation, the treatment was insufficient for the severity of the wound. The wound became infected, Patient A went into sepsis, and he spent four days in intensive care.
  • When his leg swelled, Patient B’s doctor prescribed compression therapy. Thorough wound documentation would have indicated insufficient blood flow to Patient B’s leg. A week later, Patient B’s leg had to be amputated.
  • Patient C was diagnosed with a Kennedy ulcer – a wound that can develop suddenly prior to death – even though Patient C was lying on a deflated pressure-relieving mattress. The nurse practitioner denied the bedding issue, though attention to the bedding may have prevented further aggravation of the wound. Patient C’s blood pressure dropped, and she was sent to the hospital where she died within hours.

Rising medical costs and greater demands on nurses have also increased the need for more thorough wound documentation. Frequent staff turnover makes wound documentation the only communication thread between teams of people who treat wounds over time, which can last years if improperly treated. (Most wounds can be closed within four months with attentive care.) Without thorough wound documentation, key medical information is lost, and the staff does not observe the wound trend.

Proper wound documentation is not just an academic or paperwork requirement: it can help heal wounds more quickly, reduce pain and suffering, and demonstrate to families, insurance companies, and courts that facilities have provided a diligent and attentive course of wound care.

David Navazio is Chief Operating Officer and Founder of Gentell, a Bristol, PA-based provider of advanced wound care products and services to the long-term care industry.