?? Re: creating documentation for wound assessment in OP Clinic setting.

  1. Hi All,
    I recently accepted a position in an outpatient wound care clinic located inside a hospital. The previous RN left a long time ago so it's up to me create a plan and put it in place. The current documentation is a packet that is 3-7 pages long! I'm trying to streamline the process (we will eventually be using EMR) and want to get an idea of what other RN's do in the clinic setting.
    I'm specifically interested in documentation on the non measurement days. I have several patients who come in for nurse only visits 1-2 times per week that require a dressing change...I'm not sure how this should be documented? I was thinking a simple nurses note regarding the tx change/if the pt tolerated it/any changes along with a billing sheet. Does that make sense? I've created a document to log 4 weeks of measurements/assessments on 1 page that will give a month at a glance glimpse at the wound...I was thinking the reverse side of that could be a nurses note page that allows for free text on the assessment date as well as updates on dressing change days. Does this make sense?

    Carrie RN, WCC
  2. Visit CarreBarreLPN profile page

    About CarreBarreLPN

    Joined: May '08; Posts: 70; Likes: 42
    Wound Care Coordinator; from US
    Specialty: 3 year(s) of experience in Sub Acute and Wound Care


  3. by   lostNneuro
    Wow, this is eerily similar to the situation I find myself in! OP clinic attached to a hospital with the last WCC looong gone....

    I can say on nurse visits we typically measure anyway. If not, a nursing note with the visit details should certainly work to support billing.

    I'm going to have to redo our wound detail document. A month at a glance is a great idea. Our columns are currently way to small to accurately document the details of the wound assessment.

    We might need to consult each other more often! Hope things are well.

    Ellie, RN, WCC