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Nursing Documentation & Legal Considerations in Wound Management. Sue Templeton Advanced Wound Specialist RDNS. Wound Documentation. Why document?. Initially: to record the client’s history identify aetiological factors

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nursing documentation legal considerations in wound management

Nursing Documentation & Legal Considerations in Wound Management

Sue Templeton

Advanced Wound Specialist

RDNS

why document
Why document?

Initially: to

  • record the client’s history
  • identify aetiological factors
  • identify intrinsic and extrinsic factors that may affect wound healing
  • obtain a baseline for future comparison
  • provide a legal and organisational record
why document4
Why document?

Ongoing: to

  • use in planning wound management
  • monitor wound progress
  • evaluate wound management
  • communicate to other health professionals
principles of documentation
Principles of documentation
  • timely
  • accurate and objective
  • concise
  • comprehensive
  • legible
  • Include signature and printed name
  • use only organisationally approved abbreviations and colloquialisms
principles of documentation6
Principles of documentation

“if it’s not documented it’s not done”

Vs

“documentation by exception”

principles of wound documentation
Principles of wound documentation
  • regular
  • systematic
  • standardised
  • easily interpreted
  • time efficient
  • supported by organisational protocols
  • supported by research where possible
  • used to inform management decisions
documenting the wound
Documenting the wound

Initial wound documentation should include:

  • wound location
  • date wound sustained
  • original wound mechanism / intended type of healing
  • wound classification (acute / chronic)
  • other practitioners involved in wound management
documenting the wound9
Documenting the wound
  • allergies / sensitivities
  • factors which may inhibit healing
  • medications / treatments which may inhibit healing
  • weight and nutritional status
  • factors that may promote healing
  • mobility
  • social / psychological factors
  • pain
wound appearance
Wound appearance

Factors to document regularly:

  • wound stage
  • dimensions (including sinuses and undermining)
  • tissue type/s
  • exudate type and amount
  • odour
  • surrounding skin
  • signs of infection
  • pain
tools of wound assessment
Tools of wound assessment
  • free text
  • specialised charts / forms
  • measurement grids / rulers
  • tracings
  • photographs
  • computer programs
  • volume measures
the interdisciplinary team
The interdisciplinary team

Good documentation will assist team wound management

  • nurses
  • medical practitioners
  • other health care practitioners
  • lawyers / coroner
  • investigation of concerns and complaints
care planning
Care planning
  • standard format
  • review regularly
  • set out clearly and systematically
  • must link assessment and practice
  • identify short and long term objectives
  • set review dates
  • provide supporting rationales for care
care plans
Care plans
  • hand written and paper based
  • electronically based desk top computer
  • electronically based hand held computer
  • standardised
  • blank
clinical pathways
Clinical Pathways

A clinical pathway is a documented plan of care in which treatments are based upon known best practice (evidence based) and sequenced along a specified timeline.

The main elements of a clinical pathway:

  • clinical practice guidelines
  • clinical indicators
  • variance
clinical practice guidelines
Clinical Practice Guidelines
  • a clinical pathway is supported by clinical practice guidelines
  • guidelines aim to identify interventions which will ensure the best possible outcomes
  • guidelines should be based on the strongest possible evidence (‘best practice’) to link intervention and outcome, not ‘current’ practice
the need to prove competence
The need to prove competence

Proving competence includes:

  • continual assessment and reflection of own knowledge, skills and professional judgement
  • demonstrating a commitment to improving the quality of practice
  • ensuring maintenance of professional education and skills relevant to practice
  • ensuring optimal client outcomes
the competency pyramid
The Competency Pyramid

Professional Competencies

(eg ANCI)

Career Competencies

(eg Critical Care)

Practice Competencies

(eg Wound Management)

Skill based Competencies

(eg CPR, Medication calculations)

rdns wound competencies
RDNS wound competencies
  • developed by RDNS CNC Wound Specialists
  • modelled on the ANCI Competencies
  • aims are consistent with health promotion and achievement of optimal client outcomes
  • designed for use by all RNs and ENs in a variety of settings where wound management occurs
integration into practice
Integration into practice
  • supported by policy
  • incorporated into appraisal process
  • completed every 3 years
  • self directed
  • use of real life examples
  • provision of supporting documentation
  • retained by the Nurse
available publications
Available publications

Currently available:

  • basic wound competencies
  • advanced wound competencies
  • ABPI (doppler) competencies
  • EN wound competencies

Future projects:

  • leg ulcer competency (including ABPI and compression therapy)
awma standards for wound management
AWMA standards for wound management
  • provide a framework for clinical practice grounded in theory
  • based on evidence based practice and expert opinion
  • aimed at all health professionals who perform wound management
awma standards for wound management25
AWMA standards for wound management
  • clinical practice tool
  • aid in development of policies, procedures and education programs
  • each organisation can adapt the standards according to practice setting, professional roles, legislation, governing practice and organisational requirements