Accurate wound documentation is essential to provide optimal wound care for patients suffering from various types of wounds. The documented skin and wound conditions will help physicians track the progress or lack of progress in the healing process and apply appropriate therapeutic options. Standardized documentation is needed immediately after the treatment in order to avoid losing information. Keeping detailed notes of wound care treatment will also help physicians to prove their point in possible lawsuits and save themselves from malpractice allegations. Lets see how wound documentation can be improved to facilitate better wound care.
Even though every clinician has their own way of documenting a wound healing, here are some tips to enhance the quality of documentation.
* Note Every Detail Related to the Wound Record all details related to the wound such as the type of wound, size and location, whether it has partial or full thickness, its stage, odor, drainage (if any), types/characteristics of tissues in wound bed, any undermining/tunneling/sinus tracts, wound edges, surrounding tissues, any indicators of infection, pain, interventions for healing, any conditions which would affect healing, current treatment plan and referrals, patient and caregiver education.
* Document All Medications and Wound DressingsThe physician/provider should record the medications and/or wound dressing being used at the time of documentation, and also whether it was decided to discontinue any wound treatment option during the same time along with the conditions that prompted it (for example, a particular type of gauze is no longer being used as it is not good for the wound).
* Record Dressing Changes, If Any Though most clinicians document the current conditions of the wound, they often miss out the dressing changes, patient moves or any other action they take with the patients. It is very important to document these details, especially when referring patients to other clinicians. If they are not aware of dressing changes done before, they may also change the dressing and make the condition worse.
* Support Visual Documentation If there are visuals that correspond to the notes on the size, shape, fluid and tissue type, it will be a great corroboration for your documentation. Such kind of documents will stand as a benchmark or comparison in case of similar wound care cases in the future. It is better to date each photo and add a familiar object in the photo for size comparison. By using this object throughout the wound healing stages, clinicians can document the progress better.
* Ensure Clinician Charts Are Complete While setting up medical charts, clinicians sometimes skip the sections that are not regularly used in order to save time and effort. However, if such documents are presented for a lawsuit, blank lines or boxes will be considered as lack of care for documentation. So, it is quite important to ensure that the charts are complete by either drawing a line through the box or writing N/A into it.
Benefits of EMR
With a comprehensive wound care electronic medical record or EMR, it is possible to apply all these tips effectively and improve the documentation. Here are the major advantages of a digital health record system.
* Electronic record system is customized with the required forms and templates so that you can note down every detail of wound care easily with a sheet having pre-defined boxes.
* EMR designed for wound care is customized for recording necessary documentation for procedures including debridement or to archive photos.
* With an electronic system, it is possible to institute parameters that allow you to save the changes only if you have updated the entire medical chart. This will avoid missing information in charts and leave it complete.
A digital record system will also streamline the workflow and reduce the time and effort spent by clinicians on documentation processes.