Nursing Documentation & Legal Considerations in Wound Management

1. Nursing Documentation & Legal Considerations in Wound Management Sue Templeton Advanced Wound Specialist RDNS

2. Wound Documentation

3. 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

4. Why document? Ongoing: to • use in planning wound management • monitor wound progress • evaluate wound management • communicate to other health professionals

5. Principles of documentation • timely • accurate and objective • concise • comprehensive • legible • Include signature and printed name • use only organisationally approved abbreviations and colloquialisms

6. Principles of documentation “if it’s not documented it’s not done” Vs “documentation by exception”

7. 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

8. 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

9. 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

10. 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

11. Tools of wound assessment • free text • specialised charts / forms • measurement grids / rulers • tracings • photographs • computer programs • volume measures

12. The interdisciplinary team Good documentation will assist team wound management • nurses • medical practitioners • other health care practitioners • lawyers / coroner • investigation of concerns and complaints

13. Care planning &Clinical pathways

14. 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

15. Care plans • hand written and paper based • electronically based desk top computer • electronically based hand held computer • standardised • blank

16. 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

17. 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

18. Wound management standards

19. 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

20. The Competency Pyramid Professional Competencies (eg ANCI) Career Competencies (eg Critical Care) Practice Competencies (eg Wound Management) Skill based Competencies (eg CPR, Medication calculations)

21. 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

22. 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

23. 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)

24. 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

25. 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