Week 5 | Wound Management Documentation (17170-SP)

Photo of a patient chart.

Content Outline

  • Purpose 
  • Key Elements 
    • Reason for consultation 
    • Brief medical history 
    • Wound history 
    • Factors impacting healing 
      • ​Tissue perfusion/oxygenation 
      • Nutritional status 
      • Infection 
      • Diabetes 
      • Corticosteroids 
      • Age 
      • Stress 
      • Immunosuppression 
    • Focused wound assessment 
    • Short and Long Term Goals 
    • Treatment recommendations 
    • Plan for follow-up 
    • Assessment of Healing
      • % true area reduction
      • Bates-Jensen Wound Assessment Tool (BWAT).  
      • Pressure Ulcer Scale for Healing (PUSH)  
  • Documentation formats A. Flowsheets B. Narrative C. Electronic Medical Records  
  • Photography  
  • Documentation Practice 

Objectives for Learning Outcomes

At the end of this course work the learner will be able to:

  1. Describe the essential elements to include in wound management documentation. 

  2. Identify tools utilized for assessment of healing.

Additional Information

Format: 
Video
Course summary
Available: 
01/13/2017
Expires: 
04/30/2018

Renee Anderson, MSN, RN, CWON
Certified Wound and Ostomy Care Nurse; Co‐Director, Wound Management Education Program, University of Washington School of Nursing , Seattle; Clinical Faculty, Biobehavioral Nursing & Health Systems University of Washington School of Nursing; President, Rainier Clinical Consultants, Inc., Seattle, WA

 

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