This document discusses various legal issues related to wound care documentation. It emphasizes the importance of thorough and consistent documentation to avoid malpractice lawsuits. Key points include:
1) Proper documentation is essential to demonstrate that facilities are meeting standards of care. Consistency between providers is important so documentation tells a clear story of the patient's care.
2) While perfect documentation is unrealistic, documentation should communicate comprehensive details of assessments, treatments, notifications, and other essential care elements.
3) A lack of documentation does not necessarily mean a lack of care took place, but attorneys will assume this in court. Facilities must prioritize documentation to accurately reflect care provided.
4) Turning and positioning is a common
2. Table of Contents
About the Author.........................................................................................................................................................2
Introduction...................................................................................................................................................................3
How to Keep Yourself Out of Court.......................................................................................................................4
Not Documented, Not Done.....................................................................................................................................6
Turning and Positioning.............................................................................................................................................7
Risk Assessments.........................................................................................................................................................9
Is That Ulcer Unavoidable or Not?.......................................................................................................................11
Intrinsic Risk Factors for Unavoidable Pressure Ulcers................................................................................13
Extrinsic Risk Factors for Unavoidable Pressure Ulcers...............................................................................15
Avoiding a Pain and Suffering Allegation.........................................................................................................17
Conclusion....................................................................................................................................................................19