ESSENTIAL WOUND CARE
DOCUMENTATION
PRESENTED BY: SCOTT E. ORTIZ
And
Williams, Porter, Day & Neville, PC
159 N. Wolcott Street, Suite 400
Casper, Wyoming 82601
Marta Ostler PT, CWS, CLT
Wound Care Manager
Importance of Medical Documentation

Function of Medical Documentation
Provides all the information about a specific patient that any doctor looking at the
record would need to know to treat that patient.

Significance of Medical Documentation
Essential for standards of care to be met.

Medical Billing and Coding

Standards of Care
Neglecting to document important details can lead to adverse patient outcomes and
malpractice suits. Documentation is legal protection for both patient and physician in the
event of disagreement over care.

Ethics
Adequate medical documentation assures patient confidentiality and ensures that
standards of care are met. Failure to treat illnesses to the best of a physician’s ability based
on the documented patient’s medical record compromises medical ethics and professional
conduct.
 PROPER DOCUMENTATION REQUIRES
BOTH QUALITATIVE AND
QUANTITATIVE INFORMATION
THE ONSET OF THE WOUND AND THE MECHANISM OF INJURY
ANY CHRONIC CONDITIONS THAT AFFECT THE WOUND OR PREVENT HEALING
ANY ASSOCIATED SYMPTOMS (FEVER, PAIN)
THE LOCATION OF THE WOUND
THE WOUND’S DIMENSIONS (WIDTH, HEIGHT, DEPTH)
THE COLOR OF THE WOUND
ANY ODORS FROM THE WOUND
THE TEMPERATURE OF THE SKIN
THE TEXTURE OF THE SKIN (RAISED, CONCAVE)
ANY GRANULATING TISSUE
ANY TUNNELING
ANY ESCHAR OR SLOUGH
ANY EDEMA
ANY BLEEDING
ANY DRAINAGE AND ITS DESCRIPTION (COLOR, CONSISTENCY, AMOUNT, ODOR)
THE SURROUNDING SKIN’S QUALITY
THE PATIENT’S TOLERANCE OF THE WOUND CARE PROCEDURE
ANY VITAL SIGN CHANGES THAT MIGHT INDICATE WOUND-RELATED PROBLEMS
THE RESULTS OF ANKLE-BRACHIAL INDEX MEASUREMENT
THE IRRIGATION SOLUTION USED
THE TYPE OF DRESSING APPLIED
ANY PACKING MATERIALS
ANY TOPICAL TREATMENTS
 THE CLINICAL RECORD SHOULD
READ LIKE A NOVEL . . . . . .
NOT A MYSTERY!
Documentation must accurately paint the picture of the patient.
 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 wound care documentation, you could end up in a
LAWSUIT
POTENTIAL RED FLAGS
 Illegibility,
inconsistency,contradictions
 Omissions
of date and time,
 Criticism
 Vague
of other healthcare providers,
terminology,
 Abbreviations,
 Delayed
entries,
 Inconsistencies
 Corrections,
between healthcare providers,
and opinions about the patient.
Hey! What time is it?
THAT’S BAD!!
THAT’S BAD!!
THAT’S BAD!!
THAT’S BAD!!
?????
THAT’S BAD!!
Hey, what time is it?
THAT’S BAD!!
HEY!!! WHAT TIME IS IT?
THAT’S BAD!!
THE BIG ONE!!
If it’s not documented,
it was not done!
WHAT’S MISSING?
WHAT’S MISSING?
Consistency
Times
Detailed History and Prior Treatment of Current Condition
Diagnotic Information
 Imaging / X-rays
 Doppler Study
 Arteriogram/Venogram
 vascular laboratory studies
Blood Tests
 Red
blood cell count, hemoglobin and hematocritWhite blood cell
count–.
 Platelet
 Blood
countSerum albumin.
glucose/Hgb A1C
 Wound
culture
Laboratory Studies

The CBC count to assess for leukocytosis, anemia, and/or thrombocytopenia

Analysis of the patient's basic metabolic profile to look for renal insufficiency and
electrolyte abnormalities

Determination of serum protein, albumin, prealbumin, and transferrin levels to assess
the patient's nutritional status

Coagulation studies to evaluate for abnormalities, especially if deep wound excision
is required

Tissue cultures of wound to determine appropriate antibiotic therapy
Patient Options

Supplies evidence of INFORMED CONSENT or INFORMED REFUSAL

Consent and Refusal are CHOICES

To choose, requires ALTERNATIVES

Discuss Alternatives, risks and benefits of evaluations and treatments

Review likely outcomes if treatment is withheld or refused and

DOCUMENT the patient’s ability to understand the repercussions of the refusal

FOR EXAMPLE: “ Consistent with the patient’s informed choice”

Consider dictating during your patient encounter
Discharge notes/summary
This is a crucial piece of evidence regarding the inpatient treatment of a patient. It is
important to give due importance to making a proper discharge summary as this is the
summary document that will be kept by the patient which reflects the treatment received.
Key Elements:

Final examination of the patient;

Discussion of the hospital stay, even if the time spent by the physician on that date is not
continuous;

Instructions for continuing care to all relevant caregivers; and

Preparation of discharge records, prescriptions, and referral forms.
The doctor can be held negligent if proper instructions are not given regarding the
medications to be taken after discharge, physical care that is required
STRATEGIES TO AVOID DEFICIENCIES
 Document complete diagnosis specific assessment
 Document a complete pain assessment / management
 Document complete set of vital signs (if applicable)
 Document treatments performed during visit
 Document complete wound assessment
 Document physician communication
 Document coordination between disciplines
 Document complete patient education r/T medications, treatments or
disease specific processes
NURSING CARE CHECKLIST
 ACCURATE DOCUMENTATION
WHEN DOCUMENTING, REMEMBER THE FOLLOWING GUIDELINES:
 Make documentations correct and accurate
 Show the timing and the sequence of actions
 Identify the dose, route, and time of medications
 Indicate equipment or materials used
 Use accepted terminology and abbreviations
 Label late entries and continued notes on charts
 Provide facts, not opinions
Documentation of Medical Records –Legal Aspects
Remember…

The attorneys who may represent you can draw only from the documentation
you have provided.

Your charting techniques can defeat or defend your practice in court.
Many physicians complain that they do not have
the time to write sufficient records!
“Would you rather spend the time in court for 12
weeks, 5 days a week, from 9am to 5pm?”
“The palest ink is better than the
strongest memory.”
Questions?????