Wound Care Management and Documentation Non-Compliance in Prevention and Care of Wounds

The incidence of non-compliance and adherence to best practices wound care competence continues to be an issue among the clinical staff of the Veterans Affairs Medical Center (VA). At the VA, there is a practice problem of non-compliance and adherence to best practices wound care competency as evidenced in the electronic medical record (EMR) documentation among the clinical staff. A PICOT question was developed to explore if the establishment of a staff best practices wound care policy focusing on EMR documentation will improve proper wound care management among the clinical staff. The clinical site is a hospital consisting of 40 acute care beds. A new policy adjusted documentation with the use of the Braden scale and the spinal cord impairment monitoring (SCI-PUMT) tools and documentation in the EMR at appropriate times was implemented. A pretest and posttest were conducted to determine the significance of the total documentation using the Braden or SCI-PUMT tools, total accurate documentation using the wound care tools, and the number of multidisciplinary team contacts using the EMR. The results showed no statistically significant improvement with t =1.66, p =.107, t =1.03, p = .310, and t = -0.31, p = .775, respectively. Although the above results did not show any statistical significance after two months of the project implementation, a re-implementation of the project is recommended with the elimination of the barriers encountered during the project implementation