Defensive Wound Management
Contact Pathways to Empowerment
12300 Prospect Landing
Mitchellville, MD 20721
Factual accurate, complete, and timely documentation is the key to reducing liability and increasing reimbursement. The patient record must document in a clear and systematic manner the nursing and medical care provided to the patient. Nowhere is this more critical than in the area of wound care treatment and the prevention of skin breakdown.
Wound care practitioners must clearly document assessments, interventions, patient compliance to the treatment plan, and outcomes of care. To effectively prevent and manage skin and tissue trauma, healthcare professionals need to perform accurate assessments and precisely communicate the status of skin and soft tissue. Research shows that consistent documentation is significantly improved when a standardized format is used.
Good documentation skills are crucial for improving patient care and protecting you, the professional. Because there is no universal system for describing or classifying the status of wounds, appropriate documentation is critical to 1) guide treatment decisions; 2) evaluate wound healing progress; 3) facilitate reimbursement; and 4) protect against litigation.
Prevention is ideal, which means that using a standardized risk assessment tool and skin integrity status report is essential. There are several methods of improving wound care assessment and documentation. Whatever method or combination is used, the goal should be to promote accurate, thorough, and consistent documentation of wounds.
Defensive Wound Management, published by Pathways to Empowerment, is written by Glenda J. Motta, RN, MPH, ET and Kathi T. Whitaker, RN, MSN, CETN. The valuable information and formats are invaluable for all wound care clinicians and healthcare professionals, administrators, quality improvement specialists, case managers, rehabilitation therapists, staff nurses, third-party payers, wound care product suppliers, and attorneys. Following these guidelines will improve your chances for reimbursement and decrease your risk of liability.