traumatic wound documentation

[melissakp]

I'm responsible for creating peer chart review forms and this month I've chosen traumatic wound documentation.  Does anyone have any suggestions of things I should have the nurses looking for in the charts ex; type of wound, size.... what other things do you find important for wound documentation?

[JKL33]

What is your goal? What parameters would suggest whether or not you are meeting that goal?

[melissakp]

I am just looking for nurses to document that a wound exists in the ED chart. I am looking at traumatic wounds that are the reason for the visit.  Not the nasty ulcerations/pressure wounds that wound care has been following.  

[Charge200J, BSN]

The best wound documentation done in the ED that I've ever seen is from "rovers" (aka iphone like work devices) that you quickly log into and with a few taps can upload a photo directly into the chart. Hold up a form of measurement next to the wound (eg the wrapper of a 2x2 has measuring marks on it). No explanations, no descriptions. Just snap a photo and document "see photo upload." It's time stamped and let's providers see what it actually looks like instead of hoping a staff member clicks enough boxes to accurately describe a wound. Super high staff compliance because it's so quick and easy. Helpful for inpatient care as well as they can see what it looked like on admission and throughout healing process.