Frequent Wound Care Documentation Mishaps

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 Injury Stage 2 vs. 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 order 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.

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 and documentation audits of wound care documentation will help to reduce inconsistencies.

Important Notice: The views and opinions stated in this blog are exclusively those of the author and do not reflect iWound Global, iWound Care USA, Inc., its affiliates, or partner companies. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.