Wound Documentation Standards to Help Avoid Legal Issues

Medical providers, and especially wound care providers, seem to always be under the looming shadow of lawsuits and legal issues. I have written about this before, but it continues to be an issue as I receive requests for legal reviews repeatedly. I have read many charts for legal reviews, and it actually is very straightforward to avoid or mitigate any legal problems.


Important Steps to Take When Documenting a Wound

1. If you have a wound protocol, follow it or document why you didn’t. For example, if your protocol says a bed or chair bound patient on admission is high risk, then treat them as high risk, or document why you didn’t.

2. If you use an assessment tool such as Braden Scale or Norton Scale, be sure you know how to use it properly, and use it per protocol.

3. Document all calls to a physician and the response.

4. If there is a physician order, follow it and document that you adhered to the order.

  • For example, if an order says to notify physician if there is blood in the urine and you see blood in the Foley catheter, notify the physician and document that you did notify them and what the response was.

5. If you notice a change in your patient, report it to the proper person. For example: the patient has stopped eating normally, or the patient is acting differently. In an elderly patient this could be the first sign of infection … read more