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Over-Documentation?. Key Points: If Braden shows “Standard Risk” and no other indication of Skin Integrity Problem ( ie . If WNL or Baseline), then Skin Color and Skin Condition documentation is not required
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Over-Documentation? • Key Points: • If Braden shows “Standard Risk” and no other indication of Skin Integrity Problem (ie. If WNL or Baseline), then Skin Color and Skin Condition documentation is not required • Exceptions: If there had been a previous issue but it is now resolved, you would document WNL X 1 to indicate resolution of prior issue.
Charting Skin/Wound Education Type of education, who taught, & outcomes from teaching missing Need to document learning mode plus select type of education and select who taught and teaching outcomes for each
“Turn/Reposition” transitions to “Positioning Care” • Key Points: • Legal counsel/Risk Mgr. have signed off on change • Documentation of right, left, prone, etc. reflects only the position pt. in at time of documentation; they may have just turned to that position and they may turn to a different position one minute later • Turning to different “side” not possible in every clinical situation so less extreme positioning interventions are important to address need for pressure redistribution on a regular basis • Positioning Care should be documented each time it’s done * • If patient is changing position without assistance from nursing personnel, you may also document that positioning care needs are addressed and do not need to specify that patient turned self without assistance. * Moisture control care and Pressure Redistribution care documented once per shift or if there is a change (ie. New product added during shift. Specialty bed documented when patient placed on that bed and with any subsequent change but documentation is NOT required Q shift. We are interested in your feedback on this item. We are trying to carefully balance the very real need to reduce the amount of documentation nurses must do against the need for adequate, appropriate documentation to support quality patient care. We will be collecting feedback for a month and making decisions about any needed modifications in January.
From Incision/Wound Dressing Change, specify black or white foam From # wound vac foam applied/removed, enter number when adding or removing From Wound Vac Suction, enter suction level and specify continuous or intermittent For that wound, specify which wound vac on Output section will be used to document output from this wound vac. How do I document about a Wound Vac?
