Wound Documentation

Aletha Tippett MD's picture
wound care and legal issues

by Aletha Tippett MD

Medical providers, and especially wound care providers, seem to always be under the looming shadow of lawsuits and legal issues. I have written about this before, but it continues to be an issue as I receive requests for legal reviews repeatedly. I have read many charts for legal reviews, and it actually is very straightforward to avoid or mitigate any legal problems.

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Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.

Cheryl Carver's picture
pressure-injuries

By Cheryl Carver LPN, WCC, CWCA, CWCP, FACCWS, DAPWCA, CLTC

Incorrect staging of pressure injuries can cause many types of repercussions. Incorrect documentation can also be worse than no documentation. Pressure injuries and staging mistakes are avoidable, so educating clinicians how to stage with confidence is the goal.

Tissue Analytics's picture
big data analysis for wound treatment

by Matthew Regulski, DPM

One of the most difficult challenges in wound care today is deciding exactly which treatments to use. Due to the high inaccuracy of wound evaluation techniques, specifically ruler measurements, it is extremely difficult to quantify changes in a wound's progress. In addition to the lack of an accurate and objective quality metric for evaluating wounds, modern electronic health records are simply not built to handle analysis of data

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Terri Kolenich's picture
long-term care facility pressure injury staging at admission

by Terri Kolenich, RN, CWCA, AAPWCA

Question: What are Quality Measures, how does my long-term care facility measure up, and how can we improve?

Answer: Proper pressure injury staging on admission, that's how!

Terri Kolenich's picture
compliant pressure ulcer documentation

by Terri Kolenich, RN, CWCA, AAPWCA

It has been a long week. The CMS state survey team entered your facility Sunday afternoon at 2pm. Thursday is finally here and the state survey exit meeting is only minutes away. Your heart is heavy and your mind is occupied with thoughts of an in-house acquired stage IV pressure ulcer. The surveyor observed your dressing change and reviewed every bit of documentation pertaining to this stage IV pressure ulcer. The burning in your gut has completely convinced your brain that your facility will receive the dreaded F-Tag 314 because of this in-house acquired pressure ulcer.

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Cheryl Carver's picture
eschar on heel pressure ulcer

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Knowing the difference between a scab and eschar may not seem like a big deal. However, if you are being audited, or your facility is in survey, you might think otherwise. Here are a couple of scenarios for you to think about.

Rick Hall's picture
documenting wounds

by Rick Hall, BA, RN, CWON

Wound care documentation is a hot topic with overseeing agencies dealing with the medical industry. Good documentation is imperative to protect all those giving care to patients. Documentation should be Legible, Accurate, Whole, Substantiated, Unaltered, Intelligible and Timely. If these components are not incorporated into your documentation, you could end up in a LAWSUIT.

Margaret Heale's picture
Accountability

by Margaret Heale, RN, MSc, CWOCN

Most of the residents here are elderly, though some of the more acute rehab patients are quite a bit younger than me. We actually have five women over a 100 out of 116 people, quite impressive with the eldest being 105 years old. As for me, I am a retired British matron just doing a little volunteer work near where my granddaughter works.

Cheryl Carver's picture
safety net

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

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