Legal Implications for Wound Care Part 2: Wound Documentation
Updated: Sep 2, 2022
By Katie Rizzo, BSN, RN, CWOCN
In our previous blog post regarding the legal implications around wound care, my colleague ended with a quote from Dr. Ruotsi: “Do the right thing; document that you did it; and be sure that your charting reflects your policies and procedures."(1) Proper assessment and diagnosis related to etiology of wounds are essential in the care and management of successful healing and outcomes. However, as we in the medical profession have all been taught … If it isn’t documented, it wasn’t done.
Factual and complete documentation is essential in the prevention of legal ramifications related to individuals with wounds or high risk for wound development. According to statistics on medical malpractice, 195,000 patients die in hospitals each year because of preventable mistakes. (2) More than 10% of medicolegal settlements are wound-related. (3) Incomplete or incorrect documentation breaks down communication in patient care leading to some of these preventable mistakes. As stated in one of Corstrata’s previous blogs, “proper documentation of care is key to avoiding blame in wound lawsuits.” (4) Accurate documentation of interventions related to patient assessment, treatment, and education is defensible in court and may prevent litigation altogether.
Assess What You See and What You Say!
One of the first items an auditor would review is the assessment of the wound to ensure that the assessment matches the diagnosis and etiology. If your assessment classifies a sacral pressure injury as a Stage 2, however, you describe the wound bed as a “pink superficial irregularly shaped wound bed that is 40% covered in a thin film of loose slough,” you have already committed the error of incorrectly staging a Stage 3 pressure injury.
One of the most common mistakes made among clinicians is incorrect staging of pressure injuries. While it may seem like a straightforward system for classification, without proper training, clinicians succumb to inaccurately staging pressure injuries, an error that leads to inappropriate treatment plans. For example, a patient has moved to a new area and is being evaluated by a new provider. They have a healing Stage 3 pressure injury; however, the wound bed is healthy pink with evidence of new epithelial growth. The patient does not have any records on hand from their previous treatment facility, and they are a poor historian. How would an RN, physician, or NP that is not trained specifically in wound care know what questions to ask to assess and document proper staging? How do you document the stage of a pressure injury that you are unfamiliar with without a proper wound history?
Inaccurate staging can result in the patient losing access to certain pressure relief devices due to insurance reimbursement rules. Certain support surfaces aren’t covered for a Stage 2 pressure injury on a single site. However, a documented Stage 3 or 4 pressure injury qualifies the patient for the pressure-relief equipment needed for prevention and treatment. Inaccurate staging can also put the care provider at risk should they fail to establish a proper treatment plan. In this instance, if the provider is unsure of the stage, they could document “Etiology (or stage) cannot be determined with the information available at the time of the assessment,” with a note stating that previous records will be obtained and reviewed prior to the next appointment. If accurate staging is a challenge, your best option is to consult an expert to help with reviewing and determining the appropriate stage or etiology. Inaccurate staging exposes you to potential litigation if the wound deteriorates in your care.
Along with proper staging of various types of wounds, it is important that your documentation reflect a comprehensive assessment. Document what you see. Good wound documentation by the bedside clinician should always include these basic components:
Size with measurements of depth
Presence or absence of odor
Drainage character and amount
Assessment of wound edges
Color of the wound bed
Presence and rating of pain
More detailed and comprehensive assessments would also include:
Type of tissue in the wound bed (i.e., slough, eschar, granulation tissue, etc.) clinicians without proper training often incorrectly assess wound tissue. An example would be mistaking pale slough as new skin growth. When training bedside clinicians in wound documentation, noting the color of the wound bed may be a safer way to avoid inconsistent documentation or incorrect labeling of tissue types.
If you rely on previous medical records to document a wound diagnosis and clinical presentation, keeping your scope of practice in mind is important. If your scope of practice doesn’t include diagnosis, be careful not to make a definitive statement such as, “Patient presents with a venous lower extremity ulcer.” unless you have a diagnosis from a provider or clinical evidence to back this up. Statements like, “Based on the information available and clinical presentation at the time of assessment, this wound is consistent with ________” can protect you from drawing conclusions outside your scope of practice. Be sure to back up your assessment with details and observations for your conclusion. Never state that a wound IS a particular type of wound unless the diagnosis has been confirmed.
Treat the Whole Patient, Not Just the Wound
One of the key components of complete documentation is ensuring that you are documenting proper assessment and the treatment provided. When bedside clinicians or providers think about all that they do in the course of the day, it is easy to forget to add in the current interventions being done to address the underlying disease state. For example, it’s not sufficient to document a dressing change procedure for a Stage 4 pressure injury without noting the interventions in place to off-load pressure. This applies to any type of wound… venous, arterial, diabetic, skin tears, surgical incisions, etc. Virtually all wounds have additional disease state management interventions that, if not addressed and documented, could affect not only the patient’s ability to heal but also the outcome of litigation should that happen. Documentation of what you are doing to monitor and treat the whole patient is the component of your charting that makes a treatment plan complete.
Education is The Final Piece of Good Documentation
Perhaps the most overlooked area of documentation by all bedside clinicians is the education they provide to the patient and the caregivers. Education is a form of communication that is essential in building trust between the treatment team and the patient. Through education about the disease process, treatment plan, and dressing application, we involve the patient in their own care and give them some level of control over a situation they may feel is out of their control. As care providers, we need to take credit for all of the education we provide in the course of our care for the patient. Documenting the individual response to education is equally important. Ask yourself these questions and document the answers:
Did they understand what I taught?
How do I know?
What evidence is there that they are grasping the concepts I am trying to convey?
It’s important to document if a patient is resistant to education. However, it is also important to follow up, try again, and document your repeated attempts to educate them about a particular topic in their care. For instance, a diabetic patient cannot be blamed for noncompliance and potential limb amputation if you fail to teach them how their blood sugar levels will affect their healing or how offloading their foot is essential for healing a diabetic foot ulcer. Involving the patient and caregivers in their care can often eliminate the potential for miscommunication and misunderstanding.
Good Documentation = Good Communication = Prevention of Litigation!
It is through comprehensive, consistent, and accurate documentation of wounds that we communicate as care providers. Our written communication is the document that will make its way to court in the event of litigation. Key components of preventing documentation errors in wound care are having a documentation system that is easy to use, minimizes documentation errors, and is dynamic in its presentation of information. The use of wound dimension graphs and photos can provide quick observations of wound deterioration and alert the treatment team that further evaluation and changes in the treatment plan may be indicated. Furthermore, having quick access to a certified wound specialist that is highly trained and specialized in this complex field is the best resource for preventing errors in documentation and treatment. Wound care specialists are always in demand but are limited in number. Fortunately, due to ever improving telehealth technology, access to wound consultations are more possible than ever before.
Doyle, C. (2021, October 14). Anatomy of a Lawsuit: Legal Pearls for the Wound Care Provider. Generalsurgerynews.com. Retrieved August 15, 2022, from https://www.generalsurgerynews.com/In-the-News/Article/10-2021/Anatomy-of-a-Lawsuit-Legal-Pearls-for-the-Wound-Care-Provider/64939
Stanislaw, G. 25 Facts About Medical Malpractice. Medicalmalpracticecenter.com. Retrieved August 16, 2022, from https://malpracticecenter.com/medical-malpractice-facts/
Pfaff J, Moore G. ED wound management: identifying and reducing risk. ED Legal Letter. 2005;16:97-108.
Piette, K. (2021, March 30). Wound-Related Litigation Shows Need for Documentation. Corstrata.com. Retrieved August 15, 2022, from https://www.corstrata.com/post/wound-related-litigation-shows-need-for-documentation