When long term care nurses provide wound care, they must also document all aspects of wound care using their nursing home software, as long term care facilities are highly regulated, and wound care documentation for nurses must also meet federal regulations. Wound care documentation also protects a skilled nursing facility from litigation problems from particularly sensitive families of residents who may claim that certain wound care services were not provided.
And lawsuits related to poor wound care are not uncommon. The General Surgery News notes that over 17,000 lawsuits are filed annually for pressure injuries—injuries as a result of force being applied on the skin, e.g when lifting a person onto a bed—alone. And to make matters worse, chronic wounds affect around 6.5 million patients in the US healthcare system, with over $25 billion spent in the healthcare industry to treat chronic wounds.
So how should wound care documentation for nurses be conducted? It all begins with a wound assessment to be conducted by a nurse approximately every seven days. The purpose of the wound assessment is to document the wound, its size, location, and any other changes that have occurred since the last assessment. The nurse should also take note of any new wounds that may have appeared.
There are several key elements that nurses must document in their long term care software during a wound assessment:
- Location: Nurses must use the correct anatomical terms to document the location of the wound.
- Type of wound: Wounds come in different types (surgical wounds or burns) and in different classifications. Therefore, it is the responsibility of the nurse to accurately record the type of wound the patient or resident has.
- Measurement: The size of the wound is recorded in centimeters. The length, width, and depth of the wound are documented.
- Wound bed: The wound bed is the tissue that makes up the wound. The nurse must take note of the color, texture, and drainage of the wound bed.
- Wound edges: Wound edges are the borders of the wound. They can be regular or irregular in shape. The nurse must describe the wound edges and any changes that have occurred since the last assessment.
- Drainage: Any drainage from the wound must be measured and recorded. Common types of draining include serous, sanguineous, serosanguineous, and purulent.
- Odor: Wounds can have different odors, with some lacking any odor at all. The nurse must document any odor coming from the wound.
- Surrounding tissue: The skin around the wound must be examined, with nurses documenting the color, firmness, and pallor of the surrounding skin.
- Infection: Should a nurse observe any signs of infection, they should immediately document it.
- Pain: The nurse must ask the patient or resident about any pain they are experiencing, and document the resident’s description of the pain.
- Response to treatments: The nurse must document the patient or resident’s response to the wound care treatments. This includes any changes in the wound, such as healing or deterioration.
Wound Nursing Management and Best Practices
Wound care documentation for nurses is an important part of healthcare. Unfortunately, some nurses may view wound nursing documentation as tiresome due to its detailed nature, while others may be put-off by having to enter wound care documentation into EHR and EMAR systems, as they may not be so tech-savvy.
To help with documentation and record-keeping in nursing, the Nursing and Midwifery Council (NMC) offers a code on record-keeping for wound care documentation for nurses:
- Keep good documentation in line with your practice. This includes, but is not limited to, patient records. It covers all documents that are relevant to your scope of practice.
- Complete all records at the time of care, or shortly after care is provided. If a record is extended after care was provided, be sure to include these details in the medical record.
- Identify any problems or issues that may have arisen during resident care, the steps taken to resolve them, and document them all in the care plan software. This will provide future caregivers with the necessary information they may need.
- Complete all documents accurately and take quick and appropriate action if you discover that someone has not adhered to these documentation standards.
- Make a habit of labeling important notes in the facility’s electronic records, ensuring they are well-written, dated, timed, and do not contain unclear abbreviations, jargon, or personal opinions.
- Ensure all records, data, and research findings are accurately collected and securely stored via the long term care software
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10 Tips for Nursing Home Wound Documentation
Nursing home wound documentation practices are something that every CNA learns during CNA training. Unfortunately, wound care documentation for nurses is no longer paper-based but is instead electronic in nature. Most CNAs, though, first learned to document wounds on paper. Now nursing home software and other long term care EHRs are often used as a wound documentation tool in nursing homes. To help nurses better transition into using LTC software, nursing home administrators should consider EHR training for their staff.
Whether on paper or in a long term care EHR, nurses should use the following tips for wound nursing documentation:
- Conduct a visual inspection, describing what you see: Here, a nurse should describe what they see, including information on the size of the wound, shape, color, wound edges, and the presence of tunneling. It is important that nurses do not attempt to guess the type or the stage of a pressure ulcer or injury but rather wait for the opinion of a physician.
- Perform a pressure injury risk assessment: In wound care, a pressure injury risk assessment should be completed on all patients and residents, even those who do not have any pressure injuries. This will help to identify those at risk for developing pressure injuries so that preventative measures can be put into place. Nurses should not rely on previous risk assessment scores, but should instead conduct their own assessment.
- Use precise language: When nurses are documenting wound care, they need to be very specific with the language they use. For instance, a nurse may need to communicate with the physician or the family of a resident. Therefore, all information needs to be clearly documented in the wound documentation and the physician orders. A nurse should never be vague or general in the wound care documentation.
- Record any additional pertinent information about the wound: In wound care documentation for nurses, it is important to record any pertinent information about the wound. This can include things like exudate amount, odor, pain level, and previous treatments.
- Document any wound category changes: When a wound changes category, it is important to document this in the nursing home software. This will help to ensure that the proper treatment is put into place and that the wound does not regress.
- Document patient or resident behavior: When conducting wound care, it is important to document the patient’s or resident’s behavior. This can include their compliance with wound care, their pain level, and their overall mood.
- If a patient or resident refuses wound treatment, be sure to document it: If a patient or resident refuses wound treatment, it is important to document this refusal in the long term care software. This will ensure the proper steps are taken so the wound does not worsen. Nurses must always remember that a patient or resident has the right to refuse treatment.
- Use HIPAA-appropriate photography: In wound care, it is often necessary to take pictures of the wound. When taking pictures, nurses must ensure they are HIPAA compliant and do not cause any photo violations.
- Distinguish end-of-life wounds from other types of wounds: In a long term care facility, some residents will have end-of-life wounds, also known as Kennedy terminal ulcers, SCALE (skin changes at life’s end) wounds, skin failure, and terminal ulcers. Nurses should distinguish these wounds from other types of wounds.
- Document unavoidable pressure injuries: While it is best to prevent pressure injuries, there are some unavoidable cases. When this happens, it is important to document the pressure injury in the long term care software. This will ensure the proper steps are taken so the wound does not worsen.
The Importance of Wound Care Documentation for Nurses
Wound care documentation for nurses is a vital part of wound care in long term care. It allows nurses to keep track of the wound and its progress and document any changes that have occurred. By documenting the wound assessment, nurses can provide the best possible care for their patients and residents as well as protect themselves from potential litigation.
Nursing home administrators should consider EHR training for their staff to ensure the effective use of long term care EHR software in the wound documentation process. Nurses should use precise language when documenting wound care, conduct pressure injury risk assessments, document any pertinent information about the wound, and document changes in the wound category.
If a patient or resident refuses wound treatment, nurses must remember they have a right to do so and add it to the documentation. Finally, nurses and physicians should remember to use HIPAA-appropriate photography as well as distinguish end-of-life wounds from other types of wounds.
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