Healthcare Guidelines: Accurately Assess and Document Wounds

Plus, know what else you should know to avoid mistreating of a wound

Whenever you see a wound, while a dual visit with the nurse to do a wound assessment, you shouldn’t start with “What dressing should we use?” Because frequently that's the root of the consults that you get where you need to start and where your nurses need to start anytime you see any wound, anywhere, ask these two questions. Read this expert CMS OASIS article for more information.

1) What cause this wound? Because a lot of times, what you think might have caused it is not actually the cause.

2) What's preventing the wound from healing? That could be a useful question in your initial evaluation. But it's also a useful question as you move forward in rendering care and even sometimes as you approach a wound that's just down on a stand still.

This is so important. Sometimes, your home care nurse might just totally miss on what caused a wound to begin with. And so she could really mistreat it.

Home Health Training Example: There is a wound located on the right trochanter. You got a referral to come and see a patient because this wound had gone from being 100% granular to have a necrotic simmer. The wound had been assessed and marked as a pressure ulcer on the OASIS-C and coded as a pressure ulcer. The reason for your going to see the patient was the nurse had requested that you do debride the necrosis from the center of the wound.

So, when you saw the patient even though it's on the right trochanter, he's in bed, you would think it's a pressure ulcer is to wonder what cause this wound to begin with. And you're asking him questions, “I wondered, you know, is that why do you think this wound went from nice and red to have this dead tissue on the center. Have you been laying on it?  Did you lay on it more recently?” And he said “No, I don't lay on my sides at all.” In fact he had some compressed disk he had been admitted by his orthopedist as per home care rules.

And so the nurse saw the wound on admission and assumed it was a pressure ulcer . But this man didn’t lie on his right side. So you started wondering “What would cause a pressure ulcer over the right trochanter when there is no pressure?” He had a five-year history of lymphoma. This wound turned out to be a lymphoma wound. And ultimately he did have to go in the hospice. And then you have missed several months window where he might have been treated.

Thus, you need to really ask questions. Don't just think you've got the obvious etiology. So, ask what caused this wound to begin with him. And you must validate it with the patient.

Get more sure-fire OASIS-C training at our home health conference page.