Wound Documentation

The use of electronic medical documentation in nursing has been well recognized to improve safety and quality of patient care. However, unintended software barriers pose challenges for accurate and consistent documentation. Inconsistencies were identified in wound documentation between nurses on an inpatient general medical unit. No tool to date has been implemented to help streamline nursing communication with regard to documentation of numeric categorization, location, and assessment of wounds. As a result this general medical inpatient unit utilized a paper wound location communication form in conjunction with electronic wound documentation. Due to the preferred visual learning style amongst the nurses, the form “Wound Communication” consists of an illustrated anterior and posterior view of an anatomical man and an exact chart replication of the numeric labeling and location of the wounds as seen in the electronic medical record. Utilizing this process has shown improvement in consistent evaluation and reassessments of wounds providing optimal wound care and better patient outcomes.https://scholarlycommons.libraryinfo.bhs.org/nursing_artof_innovation/1004/thumbnail.jp