1. Wound Treatment in Long Term Care
Deborah Caswell, R.N., M.S.N., N.P.-C
Clinical Director
University Vascular Associates

2. Wound Treatment in Long Term Care
Wound assessment and documentation is primarily subjective, visual pen and paper exercise
Requires good base of knowledge to perform accurately
Complexity of wound assessment can lead to inconsistent documentation

3. Wound Treatment in Long Term Care
Factors that complicate wound assessment and documentation:
Different levels of knowledge among caregivers
Multiple area of documentation for wound issues is MR
Multiple wounds on one patient

4. Wound Treatment in Long Term Care
Purpose of Medical Record
Acts as a tool for communication between caregivers to aid in coordination of care
History record to determine the efficacy of past interventions and to guide future care
Evidence of quality of care used in legal action when medical errors, physical damages, etc are alleged

5. Wound Treatment in Long Term Care
Admission assessment: Good medical record documentation begins at time of admission
Snapshot of patients status…document as much information as possible
Size location and characteristics of pre existing wounds need careful documented
Absence of wounds should be documented
Document any variation from the norm

6. Wound Treatment in Long Term Care
Risk Assessment:
Should be done at admission
Information can guide comprehensive care
CMS recommends risk assessment:
on admission,
weekly for the first 4 weeks after admission for residents at risk
Quarterly or whenever a change in cognition or functional ability develops

7. Wound Treatment in Long Term Care
Risk Assessment:
Validated risk assessment tools are powerful and accurate predictors of pressure ulcer development but they are useless if no one acts on the information they provide

8. Wound Treatment in Long Term Care
CMS recommendations:
Assess and document pressure ulcers with each dressing change
Monitor the dressing daily even when it is not changes
Weekly systematic assessment which allows for identifying subtle changes

9. Wound Treatment in Long Term Care
CMS recommends with each dressing change:
Assess location and staging
Size
Exudate
Pain
Color and type of wound bed tissue
Description of wound edges and surrounding tissues

10. Wound Treatment in Long Term Care
Regular monitoring and documentation of dressing status:
helps the provider determine the effectiveness of treatment and
ensures that the dressing is in place and
that it is appropriate for the wound

11. Wound Treatment in Long Term Care
Wound assessments should be concise and consistent
Plan of care should consider the factors contributing to the wound and set reasonable goals

12. Wound Treatment in Long Term Care
Tag F-314 guidelines CMS recognizes that pressure ulcers are unavoidable if staff documented that they took the following measures:
Evaluated the residents clinical condition and pressure ulcer risk factors
Defined and implemented interventions consistent with the resident’s needs, goals, and recognized standards of practice
Monitored and evaluated the impact of the interventions
Revised the approaches as appropriate

13. Wound Treatment in Long Term Care
Response to discovering a pressure ulcer:
Document who was notified
Note any topical care that was provided, creams, ointments, dressings, etc
Describe actions taken to minimize further damage

14. Wound Treatment in Long Term Care
Identify the wound type:
Correct identification of the wound guides care
When in doubt document what is observed

15. Wound Treatment in Long Term Care
Wound photography:
Series of images allows for more efficient and informed interventions
Wound imaging supplements but does not replace need for written documentation
Would support facilities quality, consistency, and documentation of care for the wound