Wound Warriors
" Required Documents"
First Things First
Red Flags
Clinical Curveballs
100

At Start of Care, a wound that was previously present but is now completely healed should be documented as this rather than as an active wound.

“What is a healed wound"

100

What document should be handwritten or printed and placed in the patient’s folder at home to provide an up-to-date record of all medications?”

“What is a copy or written medication list?”

100

This is the process for ordering supplies?

What is sending a communication to daisy titled Supplies to order?

200

When a surgical wound is covered by a non-removable dressing and the wound bed cannot be assessed, it is documented as this.

"What is not Healing"

200

This is how often a clinician should review the patient’s medications and update the medication list to ensure it remains accurate and current.

“What is every visit?”

200

Where should Foley catheter, IV infusion, ostomy, and bloodwork orders be documented?

What is Foley catheter orders, IV infusion orders, ostomy orders, and bloodwork orders should all be documented under the Procedures tab. If the procedure is not already listed, add the procedure first and then enter the order. This ensures the next clinician knows what is being done for the patient.

200

This is the procedure for requesting time off even if you don't have enough PTO time to take?

What is entering your time off in the ADP app and emailing Abigail.

200

What information is needed when ordering supplies for patients?

An order is required for any and all supplies being requested. The order must include the patient’s measurements, how often the dressing is to be changed, and the size and quantity of supplies needed.

300

 At Start of Care, wound documentation should include these key assessment findings: location, wound type, measurements, wound bed appearance, drainage, odor, surrounding skin, and signs or symptoms of infection.

“What are the essential wound assessment findings?”

300

At Start of Care, medication information should be documented in these three areas of the patient’s chart to ensure medications are accurately reviewed and captured.

“What is the medication list, medication reconciliation, and N0415 question of the oasis?

400

When documenting a wound at Start of Care, this should be included in the clinical uploads to provide visual documentation of the wound’s appearance.

“What is a picture of the wound?” 📸🩹

400

“This should begin at the start of care, and this notice is provided to the patient 24–48 hours before discharge.”

“What are discharge planning and the NOMNC (Notice of Medicare Non-Coverage)?”

500

When a Kaiser patient has a wound, but no wound-care orders are available, this is the process used to contact the provider for wound-care orders.


“What is sending Donna an email so she can message the doctor through the Kaiser portal?”📧 ✉️ đź’Ś đź“© 📤 📥 





500

“This document is left in the patient’s home to help track provider appointments and home care visits, reduce confusion about when the clinician will return, and decrease missed visits.”

“What is the Green Calendar?”