Proper documentation of wound assessment is critical, and wound care professionals should strive to make it as complete, consistent, and accurate as possible. It can not only make or break a defendant’s case, but can go a long way in avoiding litigation in the first place. Inconsistencies, omission of necessary elements of wound documentation, as well as misunderstandings of proper wound terminology and concepts can potentially leave glaring inaccuracies and omissions in the chart. Plaintiff attorneys and their expert witnesses will inevitably scour the chart with a fine-tooth comb and use these assessment errors and omissions to try to prove that the facility and its staff did not meet standards of care and are therefore liable for wound development and/or deterioration.

Serving as a legal nurse consultant and an expert witness, I have personally looked at hundreds of charts related to wound care litigation. I have noticed some common, simple wound assessment documentation “faux pas” in charts. These errors are committed by not only bedside nurses who are not necessarily trained in wound care, but also by trained and certified wound professionals. What follows is a quick list based on my personal observations and knowledge about standards of care:

1. Incorrect location documentation (or lack there of). This error leaves the reader wondering which wound is being assessed and where it is on the body. Use correct anatomical terminology. One of the most common errors I see is when any skin breakdown on the buttocks is described as a sacral ulcer. Does the area of skin breakdown really overlie the sacral bone, or is it on the fleshy part of the gluteus? Inner or outer gluteus? Upper or lower buttocks? Or maybe the skin breakdown is on the ischial bone – sometimes easily missed by even the most seasoned wound assessors? Or on the hip area?
2. Staging non-pressure injuries. This error is a big faux pas, and can create issues, especially in the litigious world of today. Staging applies to pressure injuries only! Once an ulcer is staged, the provider has declared it to be a pressure injury, whether it is or not. Clinicians should be particularly vigilant when it comes to ulcers on the legs or feet, and investigate if the etiology is truly pressure. Is it instead a venous, arterial, or diabetic ulcer? Or some other dermatologic condition?
3. Omission of necessary parameters such as length and width and depth. Most standards advise measuring the wound once a week. Length generally corresponds to the 12 and 6 o’clock orientation of the wound, and width is the 3 and 9 o’clock orientation of the wound. Don’t forget to assess and document any undermining and tunneling, also using the hands of the clock to document location of the undermining and tunneling. Are the wound edges attached?
4. Omission of wound bed description. Wound clinicians should think red, yellow, and black, and document percentages of each. Red or pink describes granulation tissue, although not all pink tissue is granulating. A wound may be poorly granulating or not granulating at all; look for the granulating buds in the wound bed. Yellow is slough, and black is eschar. Ideally, the provider should try to describe the yellow and black they see. Loosely adherent? Moist? Dry? Foul? Is there an odor? Is there exudate?
5. Mistaking moisture-associated skin damage (MASD) for a pressure injury. Sometimes it can be really hard to tell, and one person’s MASD (or irritant contact dermatitis) is the next person’s Stage 2. Bear in mind that MASD is always partial-thickness and superficial, although it can look very angry and red, especially if compounded with a candidal infection. If it overlies a boney prominence, then it most likely is a pressure injury, so be sure to palpate for the bone underneath. If it has devitalized tissue, then it has become or is becoming full-thickness, which would NOT be MASD.
6. Use of the term “excoriation.” The common definition of excoriation is linear scratch marks. Excoriation is NOT the superficial denuded skin of MASD. This is probably one of the most misused terms that I see in a chart.
7. Assigning a depth to a necrotic wound when the wound bed cannot be visualized. As a wound is debrided, it may get deeper, and plaintiff attorneys will pounce, declaring that the wound has gotten bigger and deeper. Rather, clinicians should use the terms “undetermined depth” or “non measurable.” If the provider still wants to indicate a depth, ensure documentation includes the fact that this is “visualizable” depth and that the wound is expected to get deeper as it is debrided.
8. Use of the term “epithelium” to describe an open wound bed. Epithelialization is the final step in wound healing and represents a healed (or resolved) wound. An open wound cannot be “epithelized” since that would indicate that its healed.
9. Not documenting wound treatments as part of the note. Although everyone’s documentation practices, protocols, and forms can differ, from my perspective it helps to include the treatments in the note, so it is clear exactly what the provider is treating the wound with.
10. Not documenting provider and family notification in the note. This omission is frequently a big issue in lawsuits, and complaints in the case frequently make allegations that neither provider nor family was notified about development of a wound nor about any deterioration.

Of course, there are many more “errors and omissions” that can occur as one assesses and documents wounds. These are just the top 10 that come to my mind. As wound care litigation is on the rise, providers should stay abreast of best documentation practices to avoid legal repercussions.

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.