Superior Documentation Means Superior Wound Care Documentation needs to be specific enough that another caregiver can clearly understand the wound presentation and its treatment. AUGUST 2012 Holly Korzendorfer and Adrianna Cantu Wounds and pressure ulcers afflicting long term care residents incite visceral reactions in lay persons due to the fragile population served and the misconception that poor care is always the causative factor. In addition, such misconceptions have been known to lead to criminal charges, malpractice suits, and federal regulations to protect this vulnerable population. As a result, there are significant regulatory guidelines for caregivers, surveyors, and suppliers as to minimal documentation requirements for all wound types. The most basic premise behind these guidelines is to document what is seen, clearly enough for another caregiver to understand the wound presentation and treatment interventions, and for a supplier to provide—and be reimbursed for—the appropriate materials needed for treatment interventions. Documentation is also critical in the unfortunate cases where a lawyer is needed to defend charges. In such cases, trouble could arise when the minimum documentation standards are not met or when contradictory information is present in the medical record. F-tags, MDS 3.0 Provide Guidance Those working in long term care are familiar with the angst prior to the survey process and the fear of being cited for insufficient care via an F-tag. The tags most commonly associated with wounds and pressure ulcers are F309 and F314. The “State Operations Manual Guidance to Surveyors for Long-Term Care Facilities” clearly states the requirements for minimal wound documentation standards and pressure ulcer risk assessment. F-tag 314 says that with each dressing change, or at least weekly, an evaluation of the pressure ulcer should be documented, including the following criteria at a minimum: location; stage; size (length, width, depth, undermining, or tunneling); exudate (amount, type, color, odor); the presence, nature of, and frequency of pain; the tissue types and color, and amounts present in the wound bed; wound edges; and the presence of infection or possible complications. Photographs may be used if the facility has a protocol consistent with accepted standards. F-tag 314 also requires daily monitoring and documentation of the ulcer if a dressing is not present, the status of the dressing and the area surrounding the ulcer, and possible complications and pain. The minimum data set 3.0 “Resident Assessment Instrument Manual” collects the following data points in Skin Conditions—Section M: pressure ulcer risk; etiology; highest-stage pressure ulcer; number of unhealed pressure ulcers of all stages, including non-stageable ones; pressure ulcer assessments, including dimensions in length, width, and depth; tissue type, including most severe; the number of worsening and healed pressure ulcers; the number of venous, arterial, and other ulcers or wounds, such as diabetic foot, surgical sites, burns, and skin tears; and skin and ulcer treatments. Page 1 of 3 Superior Documentation Means Superior Wound Care 8/1/2012 http://www.providermagazine.com/archives/archives-2012/Pages/0812/Superior-Document...