Importance of Wound Care Documentation by Nurses

Efficient wound care documentation equates to better wound care – no two ways about it. Documentation is a vital element of caring for the patient professionally, since that’s how the nursing staff can convey to the other members of the healthcare team the condition of the patient at various stages. Knowing how a patient fares currently is essential for deciding the future course of action. For chronic and serious wounds, constant monitoring is vital. It could well make the difference between healing and a fatality. When it’s that important to document wounds, you need technology to back you up such as an advanced and customized wound EMR.

The nursing staff has one of the most crucial roles to play in treating a wound. Apart from directly administering care to the patient, nurses document the stages of the wound. Performing the latter is essential to ensure professional and life-saving care. The documentation format often varies between facilities, so nurses must familiarize themselves with the format followed by their facility and follow it. Abbreviations need to be approved ones alone, while all the documentation needs to be concise and clear. And you can’t emphasize enough the importance of ensuring privacy of the patient information.

How Nurses Should Document Patient Condition

The NMC (Nursing and Midwifery Council) provides detailed guidelines on how to document a patient’s condition:

• Records must be completed either at the time of an event, or immediately following it. If the notes are updated sometime after the event, it must be recorded.
• Problems or risks that arise must be identified while the steps taken should be mentioned as well.
• It is more than important that the records are accurate. If the documenting nurse is aware of any falsification or tampering, she must immediately deal with it.
• Entries must be attributed to the nurse who made it.
• Entries must be concise, factual and free from jargon and unapproved abbreviations. The date and time of each of the entries must also be mentioned.
• Research findings and all data must be collected and treated accordingly.
• Electronic and physical records must be securely maintained.

With regard to wound care documentation, recording and documentation must include assessment findings, treatment and care rendered, and other observations made following each dressing change.

Wound Findings to be Assessed and Recorded

Among the findings that must be assessed and recorded are aspects such as:

• the wound’s inception and the mechanism behind the injury
• chronic conditions such as diabetes which could interfere with wound healing
• pain, fever or other wound associated symptoms
• wound location
• wound dimensions in terms of width, height and depth
• wound colour
• wound odors
• skin temperature
• skin texture
• presence of granulating tissue
• tunneling
• presence of slough
• edema
• bleeding
• consistency, amount, color and odor of any drainage
• quality of surrounding skin

Along with the wound assessment, nurses must also document the care given and the patient’s reaction to it:

• tolerance level of the patient to the wound care procedure
• changes in vital signs indicating wound-related issues
• ankle-brachial index measurement results
• irrigation solution employed
• dressing type applied
• packing materials used
• topical treatments administered

Customized wound care EMR software features nurses’ module as well as physician module so that both sections of the healthcare team can record and document findings, treatment and progress that can be referred by either of them. This contributes to more efficient wound care documentation which in turn directly leads to better wound treatment.

Wound Wizard is a secure web based application that uses a Software as a Service (SAAS) model, giving you greater flexibility in managing your patient documentation in real time. For more information visit http://www.woundemr.com or call 855-968-6394