Archive for the ‘Wound care documentation’ Category

Nursing documentation in wound care is a key factor in determining liability

Thursday, August 13th, 2020
Nursing documentation

The medical record is an essential piece of evidence in any legal case alleging professional negligence against wound care nurses and others.

As you know, one of the purposes of the medical record is to reflect what nursing care was given to the patient. The entries speak to the quality of the care given.

The entries are supplemented by oral testimony at trial of those whose notations are in the medical record. A jury then decides if care was given that meets the standard of care in the situation or if the caregiver failed to meet his or her legal obligation.

The following 2020 legal court decision (Nixon v. The Brookdale Hospital Medical Center, Parkshore Health Care, LLC, Four Seasons Nursing and Rehabilitation Center, and the New York Community Hospital of Brooklyn, Inc.), illustrates the importance of nursing documentation and potential liability for patient injuries and death.

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Ability of patient to provide own ostomy care called into question

Wednesday, May 27th, 2020
ostomy

As a wound care nurse, you teach your patients how to care for their wounds, including a colostomy.

You teach them as they observe treatments you provide, such as ostomy care, while they are at a clinic.

It also includes orally reciting your care as you carry out treatment and direct the patient. This empowers them to understand what is required for appropriate personal care. 

You also might write down instructions and diagrams about required treatment that patients can take home and reference.

The teach-back method of patient instruction incorporates both of these approaches. This is when you have the patient repeat back what you instruct and demonstrate the care you described.

Any patient teaching also requires that the patient comprehend your:

  • Demonstration of care
  • Verbal instructions
  • Ability to carry out the treatment
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Wound Documentation and Measurement with WoundZoom

Friday, September 29th, 2017

Does your facility have a system in place for wound documentation and measurement? Our partners at WoundZoom offer an overview of their wound management system. Find out it it’s right for you.

What are you using for wound documentation and measurement? Is it saving you time and helping your patients?

As wound clinicians, we all have the same goal: to reduce wound size and eventually heal them completely. Wound measurement is key to determining our progress and guiding our treatment decisions. In this short slide show, WoundZoom discusses how their wound management system measure and analyze tissue. For example, the system  captures percentages of necrotic, granulated, and slough tissue. Accurate analysis can then drive better wound care practices. And as we know, better practices mean better outcomes.

WoundZoom Wound Management System

(Having trouble viewing? Expand to full screen or view in SlideShare.)

To learn more, visit www.woundzoom.com. In addition, you can reach out to them directly by calling (888) 237-0546 or emailing [email protected]

Planning to attend 2017 Wild On Wounds national conference? Visit WoundZoom at booth #508 for a hands-on demonstration and to enter to win a FREE WoundZoom! (Giveaway terms and additional details available upon request).

WoundZoom WOW Giveaway

For more articles about wound care documentation check out theWCEI blog Nine Documentation Pitfalls to Avoid