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Wound Care Documentation Tips and Common Pitfalls

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Meticulous documentation of wound care, from initial assessment to ongoing treatment to wound healing progress, is an essential component of the standard of care in patients with wounds. Failure to meet this standard, especially with regard to pressure injuries in long-term care, often leads to litigation. Wound care professionals must always ensure that their wound care documentation is timely, accurate, and complete.

This authoritative and practical guide contains recommendations from leading experts in the field of wound care. Topics include the use of wound documentation standards to avoid legal issues, common wound documentation errors and ways to prevent them, and the problem of retained dressings. Clinical case scenarios are also provided.

As health care professionals who assess and document patients’ wounds, you will find this guide an invaluable resource. The recommendations of these leading experts in the field will help you provide excellent documentation and avoid the medicolegal consequences of inadequate record keeping.

This guide covers the following topics:

Wound documentation standards
How to avoid legal problems
Documentation Dos and Don’ts
Common documentation mistakes
Accidentally retained dressings
Case scenarios

Meticulous documentation of wound care, from initial assessment to ongoing treatment to wound healing progress, is an essential component of the standard of care in patients with wounds. Failure to meet this standard, especially with regard to pressure injuries in long-term care, often leads to litigation. Wound care professionals must always ensure that their wound care documentation is timely, accurate, and complete.

This authoritative and practical guide contains recommendations from leading experts in the field of wound care. Topics include the use of wound documentation standards to avoid legal issues, common wound documentation errors and ways to prevent them, and the problem of retained dressings. Clinical case scenarios are also provided.

As health care professionals who assess and document patients’ wounds, you will find this guide an invaluable resource. The recommendations of these leading experts in the field will help you provide excellent documentation and avoid the medicolegal consequences of inadequate record keeping.

This guide covers the following topics:

Wound documentation standards
How to avoid legal problems
Documentation Dos and Don’ts
Common documentation mistakes
Accidentally retained dressings
Case scenarios

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