How should our nursing team document wounds to best care for wounds and minimize risk of litigation?
Patients who reside in nursing facilities and have wounds should have excellent nursing care so that all wounds heal appropriately and that no new ones occur. Because wounds, particularly pressure ulcers, can increase the risk of litigation, it is especially important to document each wound correctly, thoroughly and regularly.
In addition, wounds are a frequent focus of state and federal regulatory survey reviews. Great documentation shows attention to detail and vigilance.
A best practice is that nursing staff record progress on each wound at least weekly, or more often if there are changes or deterioration of a wound. The progress note should include the etiology, anatomic site and the stage of a pressure ulcer. Each wound should be measured at least weekly and each note should contain the current length, width and depth of the wound in centimeters. The presence of any slough or eschar tissue in the wound bed, any abnormal odor, and the condition of the skin around the wound should be described.
The progress note also should include the current wound status compared to the previous observations, and whether the wound is improving, stable or deteriorating. It should include the current wound treatment; documentation of communication with healthcare providers, caregivers or family; and any changes to the treatments. Care plans also should be updated with any changes.
Excellent documentation leads to improved care because there is regular, focused review of the wound status and treatments. This, in turn, leads to better risk management and regulatory outcomes. If the quality of care is ever called into question, accurate and timely documentation goes a long way to show that there is a good faith effort in play.