wound care notes

[wcnurse]

I dont know if this is going on at other agencies but we are expecting accreditors to come back soon and they have given us new rules as to wound care notes. Under the blank "cleaned with" you must put what you patted dry with. If you used packing gauze, you must state exactly what size. Under "secured with" I always put Tape. Now you must specify exactly what size and type, whether micropore, transpore etc.

I also used to put under "dressing type", wet to dry. We must now put wet to dry with normal saline moistened 4x4's covered with dry 4x4. I always thought wet to dry was quite obvious.

Things sure are getting nit-picky. is anyone else having to do this. I would love someone to email me a copy of your wound care note to see if it may be easier to use then ours.

[renerian, BSN, RN]

I cannot say I have ever seen them so picky about tape but I have seen and documented the rest. Sometimes I swear they want to make everything so picky it makes people want to leave.

renerian:(

[Traveler]

I have never documented what kind of tape I'm using!!!! Geez- that is getting a little ridiculous. Most of the time I use the first tape I grab out of my bag!!!!

Ann

[hoolahan, ASN, RN]

Wet to dry can be NS or in some instances betadine, so that I can see. But pat dry?? What do they think we'd use? A dirty diaper?? Geez!! Over-regulated nonsense!!

[tburrell]

Unfortunately, we have to return to the old saying "if it is not documented, it was not done". Look at your documentation from a legal standpoint. If you go into court how are you going to prove that you used NS, betadine, GCP, etc. to clean or pack the wound, unless you documented which one you used. If you covered it with a 4x4 say so.

A jury will believe the patient every time if it is not documented. At my agency the patient signs the actual note the nurse/therapist/hha fills out. Not only does this indicate that the staff member was there at the time specified, it also indicates that the patient/caregiver agrees with what has been documented.

Tom

[renerian, BSN, RN]

Except in the case that you do not have the client sign the note so they do not see it? They cannot agree with what they do not see. Just a thought. I still think saying 1.5 inches of micropore tape is stupid. Tape should be sufficient.

renerian

[tburrell]

I believe the surveyor is asking for the width 1', 2', etc. when wanting to know the size of tape, not the actual length the nurse is appling. If they want to know that, then they are being rediculous. I would be calling the state while the surveyor was present to protest.

[wcnurse]

another classic example is the following.

Under "topical med". I always put what topical if any that is ordered. Well, now, if the order states to apply with a Q-tip, you must state "applied with Q-tip". Also, if you used kerlix or kling, it must state which size, 3" or 4" etc. what difference does it make. I've never seen a physicians order that specified a particular size tape or wrap. I mean, come on.