Documenting hospice pt wound care

  1. We are currently reviewing documentation at our hospice. Our staff will be computerized in the future but for now it is paper. How do you document wounds - do you use a separate wound care form, check sheet or in your notes. Are there any specific requirements for documenting wounds and their care in hospice. Currently we have a form where we have to write everything in - length, width, depth, location, drainage, etc, etc, etc................. I found a check sheet form but I wonder what is "required" to be documented about hospice patients with wounds. Thanks!
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  2. 9 Comments

  3. by   nurselearner
    doesn't anyone document wound care?????????????????
    Help!
  4. by   augigi
    You may get more answers in the Wound care nurse forum.
  5. by   nurselearner
    But I only want to know how hospice nurses are documenting........... others such as home health are reimbursed based on their documentation. Hospice isn't.so my question is how much documentation do we need to do?

    We are currently reviewing documentation at our hospice. Our staff will be computerized in the future but for now it is paper. How do you document wounds - do you use a separate wound care form, check sheet or in your notes. Are there any specific requirements for documenting wounds and their care in hospice. Currently we have a form where we have to write everything in - length, width, depth, location, drainage, etc, etc, etc................. I found a check sheet form but I wonder what is "required" to be documented about hospice patients with
  6. by   augigi
    No problem, good luck with it.
  7. by   river1951
    We document wounds weekly, 1st visit of the week: length, width, depth, any tunneling, color of wound bed, smell, drainage, what treatment done and freq of treatment, how patient tolerated treatment- this hasn't changed in forever, but we are associated with a home health agency and QM is tough.
    On our computer we have as graphic we can mark with location of each wound, it is efficient, if not as easy as drawing.
    good luck!
    River
  8. by   nurselearner
    Thanks. I am currently working on an algorithm for our hospice on palliative wound care............while trying to be cost effective. If anyone has developed anything to this effect I would love to hear from them.
  9. by   NRSKarenRN
  10. by   WV_heart_RN
    when i have a patient with a wound i document the specifics on it every time i visit. if the caregiver does not allow me to do a dressing change or says ' i don't want pt woke up' document it.

    i learned this the hard way!! i had a dementia patient who was contractured at the knees and was supposed to be turned by the private paid caregiver. although i was told she was doing what was needed for the patient the wounds continued to get worse. and new ones developed.

    it is a long story about what i was told and what was actually done for the patient but suffice to say the patient continued to get only worse. the family felt our wound care nurse and i were not doing our jobs and took the patient to a wound care clinic. the cws thought i was nuts until she saw how one thing was said but obviously not done.

    the bad part was the mpoa was a son and believed his private caregiver no matter what she said. the patient passed away quietly but the son was at our door for several weeks after wanting to know specifically what caused his mother's death.

    i felt that i had done everything i could but i was a little uneasy about the whole situation and had i documented enough to cover my butt if a lawsuit ensued.

    since then, i use a communication sheet along with my nurse's assessment sheet to document wounds.
  11. by   a21chdchic
    All of my patient are in facilities, so they usually do wound care, however, once a week I assess the wound and do the care to assess the wound, healing, and evaluate the need for changes. Some wounds we don't expect to heal others we do. But you assess and document all wounds the same regardless of the setting in which you are working. And you continue to treat them. There are some cases that you do treat the wounds differently than for a normal healthy person. For instance, I frequently have patients that the wound/wounds are caused not from pressure, but from tumors, or a rotting limb, such as a gangrenous limb. In these cases, I know we will not heal these wounds and we treat for comfort, to decrease odors, drainage if possible, and pain. Towards the end of the life, we decrease the number of dressing changes because it is too painful for the patient to tolerate, and it isn't helping anyway. It is not uncommon to premedicate prior to dressing changes with 20 mg. MSIR without relief or sedation for patient. But we always document the same findings as anywhere else. And we use computer charting.

    Ana

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