Wound Care Provider Documentation

Updated: Mar 7, 2019

By: KATHLEEN WATSON RN | Lead Quality Coordinator | kwatson@ameriwound.com

Documentation demons from an auditing perspective....

EMR for wound care is to stay. So it is extremely important that Providers embrace its importance and prioritize their time to accommodate avoiding its pitfalls. Acceptance comes first. If a provider does not buy in to using an EMR it is a slow climb up a long mountain on a hot day. It is a difficult climb without acceptance because EMR’s can be uniquely quirky. Embracing their quirks will ensure it is a tool and not a torment. I will identify some pitfalls I have seen and hopefully provide tips for avoidance of these pitfalls. Or at least a way out if they are inadvertently stumbled on.

As an auditor for a AmeriWound I see the following barriers to providers using the EMR as a tool.

Time constraints

Often the provider feels rushed to keep up the pace of rounds and does not do documentation until the end of rounds. I recommend that notes be written immediately after each patient is seen. Or at least that the wounds are methodically written out on paper and viewed by another set of eyes. Preferably the wound care nurse. This will ensure that the correct information is transcribed at the end of rounds. Common mistakes I see because of rushing is wound location errors. Left Vs Right.