Today's Wound Clinic - Spring 2008 - (Page 40)

instruction number. Consequently, when more than one wound is located in a general area, using descriptors such as anterior, posterior, medial and lateral, and so on can help to differentiate the individual wounds. Consistent terminology should be applied. Avoid using non-medical terms for location such as above, or below. Wound Size. Wound measurements are typically done on a weekly basis. In a recent National Pressure Ulcer Advisory Panel (NPUAP) newsletter (Fall, 2007) the recommendation was made to measure wounds using the clock method, with the 12 o’clock to 6 o’clock (or head to toe) measurement being the length, and the perpendicular to that, or 3 o’clock to 9 o’clock being measured as the width. This method is counter-intuitive to some, because for some wounds the length may be smaller than the width. The alternative is to use the longest measurement as the length, with the area perpendicular to that measured as the width. The practical reality is that one chooses a method, makes that the protocol followed, and all staff consistently measure in the same manner. By convention, wounds are normally measured in centimeters. Some clinics measure in millimeters. There is no data to support that measuring in millimeters is more accurate since most rulers are centimeter based.The clinic should decide on a method and follow it. Wound depth is measured as an absolute number accounting for the space measured from the base of the wound to the skin or epithelial edge.As an additional measurement, any undermining or sinus tracts present should be documented.The location of undermining can also be designated using the clock face technique (eg, 2 cm of undermining at 2 o’clock). Stage or Degree of Tissue Destruction. Depending on the wound type, the accepted terminology for describing the depth of tissue destruction should be utilized. For example, the NPUAP staging system for pressure ulcers should only be used for pressure ulcers. While other diabetic foot ulcer grading systems are likely superior to the Wagner system, CMS uses the Wagner Figure 1: Information should be gathered in a systematic approach. Figure 2: The cause of the wound is important for diagnosis and prognosis. TABLE 1. Risk Factors Impaired/decreased mobility. Impaired/decreased functional mobility. Co-morbid conditions such as end stage renal disease, thyroid disease, diabetes mellitus. Refusal of some aspects of care or treatment. Cognitive impairment. Under nutrition, malnutrition, and hydration deficits. A healed ulcer. The history of a healed ulcer and its stage is important, since these areas are more likely to have recurrent breakdown. TABLE 2. Would Type and Classifications Type Classification Arterial/Ischemic Burns Diabetic Pressure Surgical Traumatic Venous Partial/Full thickness Partial/Full thickness Wagner Scale Stage I–IV, Deep Tissue Injury, Unstageable Partial/Full thickness Partial/Full thickness Partial/Full thickness TABLE 3. Do’s and Don’ts of documentation Do’s Don’ts • Date and time all entries. • Facts and measurements. • Patient/family education, follow-up and referral instructions. • All contacts including phone calls, missed appointments. • Limit use of abbreviations. • Patient refusal, non-compliance with treatment. • Document what is required to demonstrate that the patient was properly cared for. • Correct chart errors appropriately. • Blame anyone. • Use non-standard abbreviations. • Obliterate any chart entries. • Make subjective statements about the patient. 40 Spring 2008 Today’s Wound Clinic http://edge.As

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Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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