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DEPARTMENTS: PRACTICE POINTS

Clinical and Documentation Management Checklist

Hess, Cathy Thomas BSN, RN, CWOCN

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Advances in Skin & Wound Care: June 2010 - Volume 23 - Issue 6 - p 288
doi: 10.1097/01.ASW.0000363556.68597.3f
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In my April column, Checklists for Compliance, I discussed how checklists could be created as written guides to assist your team in meeting key steps for compliance. Checklists are a valuable tool for clinical practice when they are carefully designed, evaluated, validated, reevaluated, and updated. A sound checklist monitors and guides your practice and assists in achieving an outcome. Now, let's begin to build one more checklist in wound care. To achieve successful wound healing, the clinician must meticulously follow every step of skin and wound management, including assessment, planning, implementation, evaluation, and documentation, hence the Clinical and Documentation Management Checklist.

Patient and Wound Assessment Checklist

Initiation and coordination of a skin and wound care plan begin with a comprehensive patient assessment. The assessment is set into motion with one-on-one discussions with the patient or caregiver and clinicians who have cared for the wound. Reviewing the patient's medical history may provide important insight into the cause of the wound. Understanding the patient's past and current family, social, and medical history may provide important insight into why the wound is not healing. As part of the checklist, the clinician would

  • review the patient's medical history
  • review the patient's family history
  • review the patient's social history
  • obtain a medication list of past and current medications and dressings
  • review all laboratory, radiology, and vascular studies
  • review the patient's nutritional status and supportive therapies
  • review (if indicated) all support surfaces and positioning devices used to manage the patient's tissue load
  • address and correct (if possible) all underlying pathologies compromising the wound healing process
  • review all physician and nonphysician consultations related to specialty management programs for skin and wound care
  • assess the patient's knowledge level related to the disease process and document any and all factors that affect learning needs.

A comprehensive wound assessment follows the patient and skin assessment. The wound assessment helps define the status of the wound and helps identify impediments to the healing process. Complete and accurate documentation of the skin condition or wound provides the clinician with the blueprint to determine its etiology.

Wound Bed Management Checklist

After assessing the patient and the wound, the clinician can develop a care plan that focuses on preparing the wound bed for healing. These goals of wound bed preparation include removing necrotic or fibrinous tissue, reducing the total number of senescent or abnormal cells, decreasing exudates and bacterial load, and increasing granulation tissue. Most wounds contain a variety of organisms. Changes in the wound bed may include

  • contamination/colonization
  • critical colonization
  • infection.

The strategy of bacterial balance stresses the need for the clinician to recognize when the bacterial load has increased through a change in granulation tissue appearance and exudate amount.

Documentation Management Checklist

Proper documentation provides guidance for appropriate management decisions, evaluation of the healing process, support for reimbursement claims, and defense for litigation. Once established, the documentation system should become the framework of clinical practice for all members of the wound care team. The documented details become the facts for a medical record. Today, we are moving to the electronic medical record (EMR). This electronic means has revolutionized the way data are collected, collated, and delivered at the press of a button. It ties the clinical, functional, and financial information for the patient's visit and proves the work performed much faster. This EMR tracks the physician's work and his/her assessment data, as well as the work performed by all members of the wound care team. As you move forward with your EMR checklist to ensure the electronic documentation that meets your clinical and operational needs, define your checklist for documentation success, which may include

  • scheduling module
  • smart EMR to meet the needs of all practicing clinicians and physicians in your department
  • interfaces to pull data in and out of your system and clinical and operational compliance and audit mechanisms to ensure success
  • compliance with Meaningful Use and Accreditation and Certification Standards
  • reporting for outcomes and benchmarking, to name a few!

At the end of the day, no matter how clinically competent we are, integrating checklists into our practice will improve our clinical and operational outcomes. If you have a checklist to share with our readership, please e-mail [email protected]. Good luck!

© 2010 Lippincott Williams & Wilkins, Inc.