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Discussion

traumatic wound documentation

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?

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

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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.  

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.

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