Treatment/Wound Documentation

[renegade.4]

Hello everyone! I was just hired as a treatment/wound nurse at a fairly new facility here in California. My new facility really needs a lot of help in the treatment department as far as paperwork. My question is what documentation should we have for wounds? As far as I can tell we only have nurse's notes and a pressure sore log and that's it. Should we have weekly documentation for non-pressure wounds as well? Is a nurse's note enough for non pressure wounds? Can you please let me know exactly which documents our facility should have for treatments in preparation for State Survey? Thank you so much!

[ashleybs222]

Hello everyone! I was just hired as a treatment/wound nurse at a fairly new facility here in California. My new facility really needs a lot of help in the treatment department as far as paperwork. My question is what documentation should we have for wounds? As far as I can tell we only have nurse's notes and a pressure sore log and that's it. Should we have weekly documentation for non-pressure wounds as well? Is a nurse's note enough for non pressure wounds? Can you please let me know exactly which documents our facility should have for treatments in preparation for State Survey? Thank you so much!

I'm not a nurse yet and i can't tell you exactly what you need, but at the facility where i do clinicals (ltc) the wound care nurse comes in once a week, and measures, documents, and takes pictures of every pressure ulcer ... Not sure about general wounds...but maybe, because she was taking pictures and documenting wounds on a patient's feet that were not pressure ulcers..hope this helps

[cindjo717]

I can only tell you what they had during my clinicals. There should be one book exclusively for wounds. All residents that have wounds are in there, and you document everything concerning the wound and care there. Just like they have one book for bowel movements, there's a wound care book. You probably know this already, but that's all I know. I haven't worked in a facility yet.

[txnurse4thewin]

Nurses notes and a pressure log? Wow... I am a treatment nurse and you should have photo documentation of every wound that comes into your facility, admission assess, and weekly assess for every wound.

Well, the photo documentation is dependent on your facility. My current facility has wagered that it would be cheaper to not buy a camera so no photo documentation.

Every wound should have its own trending sheet with measures and description. There are ready made printouts for these available.

Hope this helps some!