Nine Wound Care Documentation Pitfalls to Avoid

Medical Records Pitfalls Documentation

By Nancy Collins, PhD, RDN, LD, NWCC, FAND

Lawsuits are often settled out-of-court because the medical record documentation is not defensible. Incomplete, illogical, and inconsistent records are far too common so it important to avoid the common pitfalls.

After reviewing hundreds of medical charts involved in litigation, I noticed many of the same problems occurring in the documentation over and over. From New York to Florida to California, it is remarkable how the same inconsistencies, errors, and oversights tend to stymie the defense of a case. The goal of every health care practitioner is to have complete, accurate, and timely documentation of the medical care given to each and every patient. Here are nine wound care documentation pitfalls to avoid.

 1. Calling every skin integrity problem a pressure injury.

Patients suffer with a variety of skin integrity problems including venous ulcers, arterial ulcers, sickle cell ulcers, and diabetic ulcers, to name a few. Sometimes it may be hard to determine exactly what type of wound it is and there might be an inclination to call it a pressure injury. In a recent lawsuit it was determined that what was labeled a pressure injury was in fact a very serious bug bite that had become infected. If you do not know the origin of the wound, don’t guess.

2. Using sacrum, coccyx, and buttocks interchangeably.

These three anatomical locations are all different parts of the body. When documenting the location of a wound, it is critical to use the proper medical term. This issue gets especially confusing when one nurse is documenting a wound on the sacrum and another is saying the coccyx. This might make it seem like two distinct wounds even when they are describing only a single wound.

3. Not identifying or adequately describing wounds present on admission.

Patients typically arrive at hospitals and skilled nursing facilities fully dressed in street clothing with socks and shoes. Many times, patients might have a wound dressing in place, a sling, a cast, booties, an immobilizer or other medical device. It is imperative to do a full body inspection if that is required by the care setting. Wounds that are present on admission must be fully documented. If these wounds are discovered later, they can impact payments and legal cases.

4. Confusing left and right.

It seems simple to tell the difference between left and right but many medical records show that perhaps this is not so simple. Is it the patient’s left side or the writer’s left side? When documentation sometimes says left and then says right it appears that the staff does not know what they are doing and does not reflect well on the quality of the care given.

5. Not having a consistent system to document routine care such as repositioning.

Each institution needs to think about how to document routine care. Are you going to document it on a flow sheet? Or by shift? Or at the point-of-care? Or by exception only? It is necessary to have a system in place that is communicated to all and followed by all for consistency. If some caregivers are documenting that the patient was repositioned and others do not, it looks like the patient was only cared for part of the time.

6. Improperly documenting wound size.

There are many systems to record wound size. These include length x width x depth, the clock method, wound photography, wound tracing, or some combination method. It is very difficult to determine if a wound is truly changing in size when there are inconsistent measurements from week to week. Training should be done to improve inter-rater reliability.

7. Recording verbal or stated weights as actual body weight.

Unintended weight loss is a sticky subject in wound litigation because most patients do tend to lose body weight as they become ill and certainly as they reach end of life. However, it is difficult to defend weight losses that seem implausible. For example, a recent case showed the patient weighed 195 pounds upon admission to the skilled nursing facility. One week later they recorded the weight as 160 pounds. After investigation, it was determined that the initial weight was simply a recalled weight that a family member told the admitting nurse. If the patient had been weighed using a scale, that weight would have been considerably lower. Yet the documentation reflected a 35 pound weight loss in one week. Again, it gives the impression of poor care and makes it seems like the facility did not know what they were doing.

8. Not acting upon risk assessments that indicate the patient is at risk.

Facilities obtain wound risk assessments upon admission and periodically thereafter. The task of completing the risk assessments does not seem to be problem. The problem arises when the risk assessment indicates that there is in fact some degree of risk or likelihood of a problem down the road and there is no resultant action. If you identify risk, you must put interventions in place to mitigate that risk.

9. Failing to communicate wound status to the responsible family member. During deposition, the responsible family member is asked a variety of questions about the care and circumstances involving the wound(s). It is remarkable how often he or she states that they were never told about the wound. Medical information can be confusing and it is possible that they were told and forgot or simply did not understand what was meant by the term wound. This common situation reiterates the need to do thorough education in layman’s term and then complete and detailed documentation of that educational discussion.