Wound Care Documentation: Assessment and Intervention Mistakes to Avoid – Kim Saunders

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Wound care is a specialty for a reason. Correct etiology assignment, diagnostics, treatment, and documentation are essential pieces of knowledge in the successful management of wounds.  While this video training will focus more specifically on documentation, the assessment and intervention are the key factors to accurately reflect in the historical notes made. 

Kim Saunders, MSN/Ed, RN, CWON®, CFCN, will break down her practice tips as far as what you MUST start including in your charting.  As you consider development of an initial plan of care for a newly identified wound or an evolving treatment plan to address a non-healing wound, there are considerations that need to be made clear in your written thought process.

Fascinating and complicated patient scenarios will be presented during this discussion.  You will have the time to critically think through what went right… and what went wrong…in comprehensive wound care both documented and provided.  Learn now how to avoid the mistakes that could lead you down a frightening path, confronting personal or professional litigation.  

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1. Examine strategies to prevent medical devise-related pressure injuries.
2. Predict wound healing based on presentation and interventions.
3. Establish wound care goals.
4. Recognize challenges to seamlessly care across a healthcare continuum.
5. Correlate wound healing goals with optimal nutrition

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• Wound Healing
  • The complicated phases of healing
  • Ways to reduce the risk factors that contribute to nonhealing
• Wound Assessment
  • Skin tones
  • Clues regarding wound etiology
  • Predicting wound healing
  • Wound bed descriptors
• Principles of Wound Management
  • Wound care goals
  • Developing the comprehensive plan of care
  • Challenges to seamless care across healthcare continuum
• Nutrition Assessment
  • Align a patient’s nutritional needs with the wound healing goals
  • Address the compromised nutritional status
  • Specific nutritional needs for a pressure injury
• Special Populations
  • Neonates, geriatrics, bariatrics, spinal cord injuries
• Pressure Injuries
  • NPUAP definitions & staging
  • Assessment tools, documentation, & treatment of DTPI
  • Mucosal pressure injuries
  • Medical devise-related pressure injuries
  • Pressure injuries in the critically ill patient
  • Skin failure
• MARSI & Abrasions
  • Types of medical-adhesive related skin injuries
• Mechanical Injuries: Top-down
  • Top-down vs bottom-up tissue damage
  • Moisture-associated skin damage
  • Skin tear assessment and treatment

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