Frequent Wound Care Documentation Mishaps

Introduction

Long-term care documentation differs significantly from hospital documentation, and providers face greater responsibility in this context due to all of the wound-related lawsuits. Documentation discrepancies, on the other hand, can vary. However, there is a considerable documentation gap known between the wound center and the nursing home. When a nursing home patient attends the wound center on a weekly basis, communication is essential.

 

Frequent Mishaps

  1. Wrong wound etiology
  2. Pressure Ulcer/Injury Stage 2 versus Moisture Associated Skin Damage (MASD)
  3. Tissue Types (Scab vs. Eschar, Epithelial vs. Granulation)
  4. Wound Depth
  5. Partial thickness vs full thickness
  6. Anatomical Location 
  7. Treatment doesn’t match physician wound care order
  8. Absence of Care Coordination

Documentation has become increasingly crucial as wound care practices. Understaffing and overwork among clinicians in hospitals can lead to issues with the basic tenets of wound care. Guided clinical workflows can ease this burden on staff. The level of training and experience of the employees at a hospital is unquestionably one of its most critical foundational elements.

 

Conclusion

In every healthcare setting, there is an increase in wound-related lawsuits. The majority of these lawsuits are connected to pressure wounds. Common stumbling blocks include inadequacies in documentation, incorrect pressure ulcer/injury staging, and treatment implementation, to name a few. Weekly assessments of wound care documentation will help to reduce inconsistencies.

 

Disclaimer

The views and opinions stated in this blog are exclusively those of the author and do not reflect iWound, its affiliates, or partner companies.

 

Future Reading and References

Centers for Medicare & Medicaid Services. MDS 3.0 Manual v01 07. US Department of Health and Human Services; 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual Accessed January 28, 2022.

WoundSource: Knowing the Differences between Scabs vs. Eschar, Cheryl Carver’s blog  

https://www.woundsource.com/blog/knowing-difference-between-scabs-and-eschar

Baranowski S, Ayello E, eds. Wound Care Essentials. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

 

 

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