Part 1 in a multi-part series looking at the basics of avoiding litigation as a health care provider. No matter the setting in which we practice, as health care providers we constantly are under the threat of a malpractice lawsuit. In nursing homes the top targets for litigation are pressure ulcers, malnutrition, and dehydration. Up to 20% of all U.S. legal medical claims and more than 10% of settlements are wound related,¹ and there are more than 17,000 pressure ulcer-related lawsuits filed annually in the United States.² So, it behooves us to take the necessary measures to avoid being sued! What are the perils and pitfalls of wound care that we may encounter in our practice, and how can we best avoid them? This blog explores the various elements that can make or break a case.

Wound Documentation Basics

Importance

Adequate and accurate documentation, which is a record of the care provided, is a critical component. Unfortunately, the chart is not always complete. Over the course of my time reviewing charts relating to medical malpractice, I have found that there is no such thing as perfection. The chart can be the best tool defense attorneys have, yet it can also be the best tool plaintiff attorneys have, if you get my gist.

Purpose

What is the purpose of wound documentation? The primary purpose is communication. Communication among current providers regarding present or past care enables the entire health care team to share information about the care and treatment of the patient. Communication, of course, can be verbal or written, but it is written communication (the chart) that will make its way into court.

Consistency in Wound Documentation is Key

Communication is how we as the health care team stay informed about the patient's changing condition. Therefore, it becomes absolutely necessary that within our practice setting we review what our other team members are documenting and ensure that all documentation be consistent among disciplines. For better or for worse, bedside nurses assume chief responsibility for skin and wound assessment and documentation. Other providers (physicians and advanced practice providers) should always review nurses' wound care notes. It never looks good in court when nursing wound documentation charts "stage 4 pressure ulcer, necrotic 7 × 8 cm," and the same-day physician documentation is "stage 3, 3 × 4 cm." Which is the right one, and why aren't they documenting the same thing? This throws the entire wound documentation, and possibly the entire chart, into doubt. Consistency in our wound care documentation is key. Consistency will build trust that what is in the chart is an accurate depiction of the wound and the care provided and will hold up much better in court when presented to a judge and jury. Having a dedicated wound team or, better yet, a certified wound specialist conducting the weekly wound assessments should accomplish much greater consistency than relying on almost random bedside nurses, who may not have received wound assessment training. Wound care policies should dictate who will consistently perform the wound assessments and at what frequency.

Essential Elements of Wound Documentation

A well-designed wound care documentation form should include all necessary elements. These include:

• Location. Often in reading a chart we are not sure exactly what wound is described or where it is. And don't confuse right with left.
• Measurements, as accurate as possible, and measured consistently from week to week.
• Wound bed description, including odor and drainage and any signs of infection.
• Pain (and what was done about it). Where is the pain? "Pain and suffering" allegations are frequently part of a pressure ulcer lawsuit; however, if the pain is caused by a different condition such as chronic back pain, document this so it isn't attributed to the pressure ulcer.
• Nutrition status and what measures are in place, especially if the patient is at risk or is already compromised.
• Support surface that the patient is on, both mattress and seating surface.
• Turning and positioning measures.
• Physician and family notification. Often in a lawsuit, the family will say, "We never knew about the bedsore, or how bad it was!"
• Current treatment or whether the treatment is being changed.
• Risk status (i.e., the Braden score).
• Whether the ulcer was present on admission, or when it was first noted.

In the next blog, I examine the "not documented, not done" assumption (often used by plaintiff attorneys) and then drill down to specifics of wound documentation that either may help you stay out of court or may eventually help you if you find yourself in that pickle down the road!

References

1. Pfaff J, Moore G. ED wound management: identifying and reducing risk. ED Legal Letter. 2005;16:97–108.

2. Agency for Healthcare Research and Quality (AHRQ). Preventing pressure ulcers in hospitals: a toolkit for improving quality of care. Rockville, MD: AHRQ. https://www.ahrq.gov/sites/default/files/publications/files/putoolkit.p…. Accessed October 14, 2018.

About the Author

Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.