Point Care
Resources for Pointcare can be found here.
What is the Home Health Learning Center?
Wound documentation occurs here
What is the ICC - Integumentary Command Center?
Wound Care is required to be skilled or non-skilled in home health?
What is skilled?
If the patient is found with a wound the skilled clinician should add the wound in the ICC, True or False.
What is true?
This action sets up each subsequent clinician to document the wound care provided correctly
Wound to left lower extremity, healing, patient caring for wound themselves and are competent, following up with PCP routinely. Skilled or Unskilled
What is unskilled?
Once a wound is healed and deactivated, a new wound should be entered if the same wound opens back up. True of False
What is False? Reactivate the "healed wound".
What is location of wound, cleansing solution, dressing type, frequency of dressing change, whether or not patient/caregiver is changing dressing at all, and who gave the order?
Changes in wound condition or condition of patient should be reported how often?
What is as notified or identified?
In the ICC (Integumentary Command Center) - the wound is what color when documentation on the wound is complete.
What is Blue?
An example of best practice when documenting patients response to wound care
What is how the patient specifically tolerated the wound care treatment?
EX: Patient verbalized slight discomfort when bandage was removed. Once cleansed and new dressing was placed patient verbalized comfort.
What are the 5 OASIS Quality M-items related to wound care?
What is M1306, M1307, M1311, M1330, M1340?
Supply ordering can vary based on the payor, True of False
What is true?
It's important to change wound care order into what tense for subsequent visits
What is past tense?
Visit Note section titled VISIT OVERVIEW/PLAN:
Nursing assessment: wound healing, continue POC
Nursing plan: continue POC
Should be documented like this?
What is ?
Nursing assessment: wound slow to heal and has decreased by 0.2cm since last SN visit. Patient continues to apply pressure which is impacting wound healing but is unable to completely stay off wound due to mobility, strength and lack of around the clock support.
Nursing plan: Follow up on new cushion requested from Dr Smith, Sn will also request add of protein to diet