10 Essential Elements of Wound Care Documentation

Many Americans living with chronic wounds are extremely vulnerable to COVID-19 and are under the care of home health and senior living providers. To better serve this vulnerable population, Netsmart hosted “Creating a Successful Wound Care Program Today and Beyond COVID-19.”

Amy Cassata, RN, WCC, Swift Medical VP of Clinical Operations and Hannah Patterson, Netsmart VP/GM of Post-Acute Operations, discussed industry challenges and best practices to improve wound care management and optimize patient outcomes.

Biggest challenge impacting wound care 

As clinicians work to deliver care, documentation can, at times, be a secondary priority. For the busy clinician, notes may be jotted on a piece of paper and pocketed, only to wind up in the spin cycle at the end of the day. 

Concern about proper and timely documentation was underscored by webinar attendees. In a poll conducted at the outset of the webinar, 31% of participants voiced that incomplete and inaccurate documentation was the largest challenge facing their wound care programs.  

10 essential elements of wound care documentation

For Amy Cassata, the successful wound care program must begin with a strong foundation in documentation. Cassata states that these ten elements of documentation are necessary to deliver holistic care: 

1. Wound type identification

2. Specific wound location

3. Determination of acquired status

4. Standardized measurement practices

5. Description of wound bed

6. Recording of patient pain level

7. Detailed description of treatments 

8. Comprehensive report of interventions

9. Documentation of nutritional needs 

10. Strategy for physician/family notification

Incorporating these ten documentation strategies into a wound are program creates consistency of information, ensuring clinicians are able to “care for the whole person, rather than care for the hole in the person,” said Cassata. 

Delivering better care with better data 

To make these documentation practices a reality, Cassata highlights the benefits of leveraging virtual care technology like Netsmart Wound Care Management powered by Swift, a solution that allows for real-time monitoring of wounds, among other invaluable functions. 

She further explained, “If you have that solution in your nurse’s hand, you have more complete documentation. That complete documentation will ensure data is more accurate.”

In a second poll question, webinar attendees were asked where they saw the most opportunity to deliver better wound care. For 50% of the audience, leveraging smart technology was the clear solution for better documentation at point of care. 

With more accurate, standardized data, clinicians can provide better care to the individual. With a virtual care solution, clinicians have complete visibility into real time rather than a bifurcated view. 

Even as a patient moves across the healthcare continuum, virtual care ensures that all information is conveyed consistently to the next point of care. 

As COVID-19 continues to impact the way care is delivered, it is vital that organizations harness the power of existing technology to meet and defeat new challenges. By implementing a virtual care strategy, organizations can have better visibility of wound care populations, while simultaneously solving for documentation issues that have long plagued clinicians.  

Watch the complete webinar here.