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Wound Care Documentation Standards

Speaker: Lisa Gould, MD, PhD, FACS

Documenting a wound assessment is a critical part of wound care. The clinician’s documentation is the primary form of communication with different providers on the team and is the only way to know whether a wound is improving or deteriorating. This webinar will compare methods of wound documentation and demonstrate how newer technology can be incorporated into the busy clinician’s workflow. Examples of documentation supporting the plan of care will be provided.

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Wound Documentation: Saving Time with Technology

Wound documentation methods such as digital measuring tools, mobile tools, and customized electronic medical records can save time and enhance the quality of care. Integration of these new technologies into wound care can help clinicians spend more time with their patients and less time charting. This white paper provides an overview of wound documentation, with a focus on specific technological advances. It also describes ways in which a consistent wound assessment and documentation process can lead to better wound prevention and care.


Quick Facts – Wound Documentation Technologies

This fact sheet covers the latest information on documentation in wound care. The print-friendly format is perfect for posting on the bulletin board or distributing to your nursing staff at in-service.


Understanding Wound Documentation Goals for Your Care Setting

Up to 20% of all US medicolegal claims and more than 10% of settlements are wound related. Documentation is essential for all health care settings; however, there are differences in each setting. Knowing…

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Using Wound Photos to Enhance Your Documentation

Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient’s medical record. Pictures in wound care can be used to ensure accuracy…

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How Streamlining Wound Documentation Improves Continuity of Care

Continuity of care has always been the heart of practicing medicine and is especially important for wound care. Continuity of care in wound management…

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Optimizing Your Wound Care Workflow to Improve Outcomes

Multiple electronic medical record (EMR) systems are being utilized across the health care spectrum. However, these systems do not always contain documentation elements that capture specialty care such as…

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How Much Do You Know Wound Documentation?

Take our 10-question quiz to find out.

Terms to Know: Wound Care Technologies

Benchmarking: Benchmarking is using published wound outcomes reported by others as a framework within which to assess your facility’s outcomes and potential need for improved care.

Chronic wound: A chronic wound is a wound that has failed to progress towards healing in 30 days or more. There are varying factors that can cause a wound to stall, such as infection or a prolonged inflammatory phase. It is important to document the wound’s progress, any stalling factors, and interventions put into place to restart the healing cascade.

Digital wound measuring tool: Digital wound measuring tools include devices that may provide two- or three-dimensional assessment (length, width, depth, surface area) of a wound with electronic medical record software integration and may not require physical contact.

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